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THE JOURNAL OF THE 
LOUISIANA STATE MEDICAL 

SOCIETY 


Formerly New Orleans Medical and Surgical Journal 


VOLUME 126 


JANUARY, 1974 


through 


DECEMBER, 1974 


INDEX TO PAGES OF VOLUME 126 


Pagres 

No. 

Month 

Pages 

No. 

Month 

Page* 

No. 

Month 

1-36 

1 

January 

149-188 

5 

May 

313-348 

9 

September 

37-76 

2 

February 

189-236 

6 

June 

349-388 

10 

October 

77-112 

3 

March 

237-272 

7 

July 

389-420 

11 

November 

113-148 

4 

April 

273-312 

8 

August 

421-462 

12 

December 


December, 1974 — ^Vol. 126, No. 12 


1 


457 


health sciences 
university of MARYLAItt 


The Journal of the 
Louisiana Sfafe Medical Society 

Established 1844 

Published by The Journal of the Louisiana State 
Medical Society, Inc., under the jurisdiction of the 
following named Journal Committee: 

A. V. Friedrichs, MD, Chairman 
H. H. Hardy, Jr., MD, Vice-Chairman 
Sam Hobson, MD, Secretary 
Ralph H. Riggs, MD 
John B. Bobear, MD 

EDITORIAL STAFF 

Mannie D. Paine, Jr., MD, Editor 
Zelda N. Cooney, Editorial Assistant 

H. Ashton Thomas, MD, General Manager 

Margaret S. Bidwell, Executive Secretary 
1700 Josephine Street 

COLLABORATORS — COUNCILORS 
Lawrence R. Kavanagh, MD 
John Tanner, MD 
James W. Vildibill, Jr., MD 
Sam L. Gill, MD 
Stanley R. Mintz, MD 
Robert L. diBenedetto, MD 
Conway S. Magee, MD 
T. E. Banks, MD 

SUBSCRIPTION TERMS: $8.00 per year in ad- 
vance, postage paid, for the United States; $10.00 
per year for all foreign countries belonging to the 
Postal Union. 

News material for publication should be received 
not later than the first of the month preceding pub- 
lication. Orders for reprints must be sent in dupli- 
cate when returning galley proofs. 

Manuscripts should be addressed to the Editor, 
1700 Josephine St., New Orleans, La. 70113. 

Although effort is made to publish only accurate articles 
and legitimate advertisements, the Journal denies legal re- 
sponsibility for statements, opinions, or advertisements ap- 
pearing under the names of contributors or concerns. 


458 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


$6.00 Per Anmim, $1.00 Per Copy 
Vol. 126, No. 1 


JANUARY, 1974 


Published Monthly 

1700 Josephine Street, New Orleans, La. 70113 


A Comparison of Two Methods of Determining 
Drug Use Among University Students 

• This study was designed to provide two types of information 
simultaneously. First, we compared in terms of time and cost the 
value of a mailed questionnaire and a "face-to-face” interview. 
Statistical tests show that the two types of information gathering 
techniques yield similar results. The "face-to-face" interview ap- 
proach was more time-consuming (approximately 45 minutes per 
session) and was six times more costly than the mailed questionnaire. 

Second, we measured the patterns and levels of drug use among 
undergraduates on a southern university campus. Student use of 
marijuana, barbiturates, amphetamines, and hallucinogens was 
studied. 


PATTERNS of drug use in the United 
States have undoubtedly changed dur- 
ing the last decade. It is difficult, how- 
ever, to distinguish between the real 
changes and those apparent changes which 
are derived primarily from our increased 
awareness of the problem. 

In an attempt to sort out the real from 
the apparent, there have been many studies 
of drug use in a large number of diverse 
populations. Because there is a deep- 
rooted feeling that drug abuse has in- 
creased most markedly among white mid- 
dle class young people — particularly col- 
lege students — a considerable amount of 
research effort has been directed toward 


From the Tulane University School of Medi- 
cine, Department of Psychiatry and Neurology, 
New Orleans. 


PETER RABINS, MD 
WILLIAM C. SWANSON, PhD 
DONALD M. GALLANT, MD 
New Orleans 

assessing the amount of drug use in this 
group. 

A major task facing researchers has 
been the development of a measuring in- 
strument and methodology which yield 
reliable and valid results. Since drug use 
is, for the most part, illegal and usually is 
associated with strong moral sanctions, a 
question arises as to whether or not re- 
spondents give truthful answers to ques- 
tions about drugs. 

The purpose of the present study was 
two-fold. First, an attempt was made to 
measure drug use in a population of uni- 
versity undergraduates. The second goal 
was to evaluate the reliability and validity 
of data on drug use by employing two sim- 
ilar types of questionnaires administered 
in a different manner to two separately 
selected random samples from the same 


January, 1974 — Vol. 126, No. 1 


1 


DRUG USE AMONG UNIVERSITY STUDENTS— RABINS, ET AL 


population of undergraduates. It was 
planned to evaluate the comparative value 
of the two types of questionnaires in terms 
of time, cost and effort. 

Method 

The two questionnaires asked essential- 
ly the same questions. The first question- 
naire was designed to be administered in 
a “face-to-face” situation by a trained in- 
terviewer; the second was designed for 
self-administration and was mailed to a 
different- group of students. The major 
difference in the two measuring instru- 
ments involved the absence of “open- 
ended” questions in the mailed question- 
naire. Most of the interview items were 
drawn from Eells,^ Goldstein, ^ and Barter^ 
while others were developed by the 
authors. 

Two random samples were taken from 
the 4,032 member undergraduate student 
body of a private southern university. The 
sample drawn for the “face-to-face” inter- 
view consisted of 288 students. Two alter- 
nates for each primary interviewee were 
also randomly selected. The written ques- 
tionnaire was mailed to 1,014 randomly 
selected students. The different size of the 
two samples was dictated by time and 
cost factors. 

Forty of the mailed questionnaires could 
not be delivered for various reasons: the 
student dropped out of school, moved and 
left no forwarding address, or was out of 


the country participating in the junior 
year abroad program. 

There was an initial return of 59 per- 
cent of the 974 questionnaires which were 
delivered. A follow-up letter requesting 
that the respondent return his completed 
questionnaire yielded an additional 18 per- 
cent. A total of 77 percent of self-admin- 
istered questionnaires was returned. 

With regard to the verbal interviews, 
67 percent of the initial contacts yielded 
interviews; 27 percent of the primary in- 
terviewees could not be contacted or broke 
appointments; and 6 percent refused to be 
interviewed. In six cases neither the pri- 
mary interviewee nor the two alternates 
could be reached. Therefore, 282 inter- 
views were completed. 

Statistical tests (Chi square) showed 
that there were no significant differences 
(P > .05) between the two samples for 
the variables of age, sex, and class in 
school. 

Results 

The frequencies of drug use reported on 
the self-administered and verbal interview 
questionnaires are compared in Table 1. 

Chi square analysis of these results 
shows no significant differences between 
the questionnaires except for reported al- 
cohol and tobacco use. Since alcohol and 
tobacco are commonly used legal drugs, 
estimates of how often these substances 
had been used are probably difficult to 
make and may be unreliable. A more ap- 


TABLE I 

FREQUENCY OF REPORTED DRUG USE 
(In Percentages) 

Never I - 10 Times More Than 10 Times 


Interview Mailed Interview Mailed Interview Mailed 
Drug (Percent) (Percent) (Percent) (Percent) (Percent) (Percent) 

Amphetamines 62 67 22 16 15 16 

Barbiturates 81 82 12 13 6 5 

Cocaine 89 90 9 9 2 1 

Alcohol 2 9 1 6 96 84 

Tobacco 46 31 7 23 48 47 

Glue 98 98 2 2 — — 

Tranquilizers 76 79 13 12 11 8 

Hallucinogens 72 74 14 18 13 9 

Marijuana 39 37 12 20 50 43 


2 


J. Louisiana State M. Soc. 


DRUG USE AMONG UNIVERSITY STUDENTS— RABINS, ET AL 


propriate question for alcohol and tobacco 
would have involved an estimate of the 
frequency of use. 

A major difference between the self- 
administered and the verbal interview 
questionnaire involved the completion rate 
of the individual items. For example, the 
response rates to questions involving the 
use of marijuana averaged 90 percent on 
the mailed questionnaire and 96 percent on 
the “face-to-face” interview. The response 
rates to questions on tranquilizers were 70 
percent and 97 percent for the self-admin- 
istered and verbal interviews respectively. 
The distribution of types of answers to 
these questions, however, did not differ 
significantly. Each type of completed 
questionnaire, in other words, presented 
essentially the same picture of drug use. 

The “face-to-face” interview technique 
was six times more expensive than the 
mailed interview. In terms of determining 
the frequency of drug use and the types of 
drugs used, this interview offered no real 
advantage over the mailed questionnaire 
since these two types of data-gathering 
techniques yielded essentially the same 
results. 

Our expectation that persons questioned 
about drug use in a “face-to-face” inter- 
view would feel threatened and more vul- 
nerable to identification than those who 
received the mailed questionnaires was 
not borne out. Our data corroborate those 
of King^ who found that the identifiability 
of his respondents did not significantly 
alter response rates or rates of reported 
drug use. 

Levels of Drug Use 

Table 2 shows the reported history of 
drug use among the students we studied 
and among the 26,000 students in the 
Denver-Boulder area studied by Mizner, 
Barter and Werme.® Similar data are pre- 
sented in a larger report prepared for the 
Bureau of Narcotics and Dangerous Drugs 
by Barter, Mizner and Werme.® 

In every drug category, compared with 
Mizner’s findings, our data show that a 


higher percentage of students had used the 
drug in question at least once. It does ap- 
pear that drug usage has increased since 
1969. 

TABLE 2 

REPORTED DRUG US^GE: A COMPARISON OF 
MIZNER’S STUDY AND THE PRESENT STUDY 


(Usage at Least Once — in Percentages) 


Drug 

Mizner 

Present 

Study 

Marijojina 

26.0 

61.0 

Amphetamines 

14.4 

38.0 

Hallucinogens* 

5.4 

28.0 

Barbiturates 

— 

19.0 

Narcotics 

— 

— 


* LSD, mescaline or psilocybin. 


Marijuana 

Forty-four percent of the students we 
surveyed reported that they are still using 
marijuana. Nearly half of these (49 per- 
cent) said that they had used the drug 
during the week preceding the study. 
Seventy-seven percent tried marijuana for 
the first time out of curiosity, and 17 per- 
cent tried it because of peer pressure. Sim- 
ilar findings have been reported in other 
studies. A Department of Public Health 
and Welfare survey in San Mateo, Cali- 
fornia® in 1970 showed that 50.9 percent 
of the senior high school students had used 
marijuana at least once. A January, 1971 
national survey of college students, con- 
ducted by Dr. George Gallup^ on 63 cam- 
puses, found that 42 percent of the stu- 
dents had used marijuana at least once. 
This was double the 1968 figure and eight 
times the 1967 figure. 

Barbiturates 

It appears that barbiturate usage is not 
widespread among college students cov- 
ered in this study. Only 19 percent of the 
students surveyed have ever used any 
form of this class of drugs. At present, 
only 8.5 percent of the students we sur- 
veyed are still using barbiturates. 

Amphetamines 

Amphetamines, as contrasted to bar- 
biturates, proved to be relatively popular 
among college students in the current 


January, 1974 — Vol. 126, No. 1 


3 


DRUG USE AMONG UNIVERSITY STUDENTS— RABINS, ET AL 


study. Thirty-three percent of the stu- 
dents in our sample reported trying am- 
phetamines one or more times. Twenty-six 
percent were still using amphetamines at 
the time of the interview. 

The great majority of amphetamine 
users, 87 percent, began using the drug to 
help them study, and another 4 percent 
began use with the specific purpose of 
achieving a “high.” The remaining 9 per- 
cent gave a variety of reasons. Ninety 
percent of the students taking the drug 
use it as an aid to studying. None of the 
students interviewed ever used an amphet- 
amine intravenously. 

Hallucinogens 

The three major hallucinogens common- 
ly found on college campuses (LSD, mes- 
caline, psilocybin) have been used at least 
once by 28 percent of those interviewed. 
More than half of these users had com- 
pletely discontinued use of hallucinogens 
by the time of our interview. 

Curiosity motivated most of the users 
to try hallucinogens for the first time. 
Eighty-one percent of our respondents 
said that they initially used one of the hal- 
lucinogens because of curiosity about their 
highly touted psychedelic effects. An addi- 
tional 10 percent said they were respond- 
ing to peer pressure, and 7 percent said 
they tried it, “for the feeling.” Asked 
about reasons for present use, 42 percent 
of the users said, “for the feeling,” 19 per- 
cent stated only, “I enjoy it,” and 15 per- 
cent believed that the drugs enhanced 
their creativity. The remaining 24 percent 
gave a wide variety of reasons for con- 
tinued use. 

Of those who discontinued use of hallu- 
cinogens, 20 percent did so after experi- 
encing or witnessing a “bad trip.” Sixteen 
percent feared possible damaging physical 
or psychological effects, and 5 percent said 
that they feared arrest or could not obtain 
the drug. 


Summary 

Our data, as compared with previous 
studies on other university campuses, in- 
dicate that drug usage has increased since 
1969. With the exception of marijuana, 
which enjoys the greatest popularity of 
all the illegal drugs and which was used 
at least once by 61 percent of the students 
we interviewed, drug use appears to be 
restricted to a minority of students. In 
the case of amphetamines, however, a sub- 
stantial minority of 26 percent are using 
some form of this class of drug — usually 
as a stimulant to help them study. Al- 
though 28 percent of those interviewed 
had tried hallucinogens, only 12.3 percent 
were still using these drugs at the time of 
our interview. 

Similar self-administered and inter- 
viewer-administered questionnaires were 
distributed to two random samples of col- 
lege undergraduates. No significant dif- 
ferences were found between the two 
groups for illegal drug usage. The comple- 
tion rate of the self-administered question- 
naire was lower, but the distribution of 
response for each question was the same. 
The results indicate that the additional 
time and money spent on the “face-to- 
face” interview were not worthwhile. 

References 

1 Eells K: A survey of student practices and atti- 
tudes with respect to marijuana and LSD. J Consult 
Psychol 15:459-67, 1968 

2. Goldstein J, Korn JH, Abel WH, et al : Social 

psychology and epidemiology of student drug usage. Car- 
negie Mellon University of Pittsburgh, Report No. 70-18, 
1970 

3. Barter J, Mizner G, Werme P: Patterns of drug 
use among college students in the Denver-Boulder metro- 
politan area. Bureau of Narcotics and Dangerous Drugs, 
Washington, D.C., 1970 

4. King F: Anonymous versus identifiable question- 
naires in drug usage surveys. Am Psychologist 25:982- 
985, 1970 

5. Mizner GL, Barter JT, Werme PH: Patterns of 

d’^ue USA srnong college students: A preliminary report. 
Am J Psychiat 127:15-24, 1970 

6. San Mateo County, Department of Public Health, 
Research and Statistics Section. Five mind-altering drugs 
(Plus One), p5, 1970 

7. Student use of drugs rising, Gallup finds. Los An- 
geles Times, (Jan 17) 1971 


4 


J. Louisiana State M. Soc. 


Industrial Noise and Hearing Loss 

• "Physicians, researchers and insurance companies have long ex- 
pressed an interest and have issued warnings regarding the hazards 
of undue noise exposure. Unfortunately, however, their voices have 
gone virtually unheeded. The story is different now." 

C. O. ISTRE, JR., PhD 
W. RUBIN, MD 
R. MAAS, EdD 
New Orleans 


T>URE tone audiometry is assuming an 
increasing role in industrial hearing 
conservation. Physicians, researchers and 
insurance companies have long expressed 
an interest and have issued warnings re- 
garding the hazards of undue noise ex- 
posure. Unfortunately, however, their 
voices have gone virtually unheeded. The 
story is different now, and the major 
reason is the bite of federal legislation 
such as the Williams-Steiger Occupational 
Health and Safety Act of 1970.^ In addi- 
tion to federal legislation, some states have 
inaugurated their own specifying limits of 
noise exposure for employees. More can 
be expected. 

Although human hearing has a fre- 
quency range around 20-20,000 Hz, it is 
not necessary to check each frequency to 
determine the harmful effects of noise 
exposure. In reality, a clinician simply 
samples the ear at discrete frequencies 
(500, 1000, 2000, 3000, 4000 and 6000 Hz) 
and plots an audiogram by noting the least 
intensity needed to elicit a response at 
these frequencies. These threshold checks 
can be obtained through use of manual or 
self-administered automatic audiometers. 

The traumatizing effects of noise upon 
delicate inner ear structures have been 
largely ignored because disruption to the 


Dr. Istre is associate professor. Department of 
Otolaryn8;olosry, Tulane University School of 
Medicine, New Orleans. 

Dr. Rubin is associate professor. Department 
of Otolaryngolo^, Tulane University School of 
Medicine, New Orleans. 

Dr. Maas was the Director of Hearing Conser- 
vation, Employers Insurance of Wausau, Wis- 
consin. He died May 30, 1973. 


employee’s life-style is minimal during the 
early stages of noise induced hearing loss. 
This is not to say that temporary threshold 
shifts (TTS) go unnoticed, because at the 
end of a working day frequent complaints 
of muffled speech and ringing ears (tin- 
nitus) are common. As the exposure peri- 
ods are extended into days, weeks, months 
and years, the employee’s audiogram dem- 
onstrates a decided change in hearing 
ability. The appearance of marked perma- 
nent threshold shift (PTS) adds a new 
dimension to what was earlier a nuisance 
factor, and hearing loss now involves sev- 
eral frequencies. 

The significance of this change is the 
fact that inner ear hair cells’ destruction 
includes those frequencies used in under- 
standing conversational speech (3000, 
2000, 1000 Hz). A marked deficient for 
these frequencies gives the employee the 
unique ability to hear speech, but not 
understand it. This is because the hearing 
loss lies in the consonant range upon 
which intelligibility of speech is based 
(Fig 1). The employee with a noise in- 
duced loss now hears mostly vowels. Since 
intelligibility of speech is directly related 
to hearing, it is at this juncture in a pro- 
gressive hearing loss that the employee 
and employer become concerned about the 
noise problem. Unfortunately for the vast 
majority, remedial procedures are too late 
because they will not restore permanently 
damaged inner ear tissues. 

The cumulative effects of noise are 
graphically illustrated in recent findings 
of an experimental Multiphasic Health 
Screening Project, Tulane University 
School of Public Health and Tropical 


January, 1974 — Vol. 126, No. 1 


5 


NOISE AND HEARING LOSS— ISTRE, ET AL 


PURE TONE AIR AND BONE AUDIOGRAM 

CYCLES PER SECOND (Hz) 



Relationship of Vowels and 
Consonants to Pure Tone Screening 
Audiogram 

Fig 1. Relationship of vowels and consonants 
to pure tone screening audiogram. 

Medicine (TMHP). In this project, 22,188 
asymptomatic adults were administered a 
battery of screening tests over a four year 
period.^ The mean participant age of two 
different sampling periods, covering the 
first 12 months and last 9 months of op- 
eration, was 52 years. Hearing checks 
were administered by non-medical person- 
nel utilizing four self-recording, fixed- 
frequency automatic audiometers. 

While it is true that only certain mini- 


mal information can be obtained from 
pure tone audiometry, generalizations 
based upon configurations consistent with 
clinical pathology are permissible. As in 
any screening evaluation, an accurate 
diagnosis is directly dependent upon a 
more comprehensive and detailed exami- 
nation. Various audiogram configurations 
were observed at the THMP Project, and 
these findings have been discussed else- 
where.®-^ But one specific configuration, 
which occurred over and over again, re- 
lated to those participants with histories 
of occupational or military noise exposure. 
Since the resulting change in pure tone 
sensitivity because of excessive noise ex- 
posure follows a progressive pattern (Fig 
2, 3) the incidence of noise induced hear- 
ing loss among participants can be docu- 
mented. 

The fact that noise is injurious to hear- 
ing is supported by results from the 
TMHP facility. There is a decidedly 
marked reduction in threshold sensitivity 
for male participants (Fig 4) . How many 
of these participants were aware of the 
hearing loss remains unanswered because 
these statistics were not tabulated. But 
the authors would submit that the vast 
majority of younger participants did not 
give the reduced sensitivity much thought. 



Fig 2. Beginning noise induced hearing loss. 


6 


J. Louisiana State M. Soc. 



NOISE AND HEARING LOSS— ISTRE, ET AL 



Advanced incidence of noise induced hearing loss, 


Fig 3 


Hopefully, the referring physician called 
this to the attention of his patient. 

Results from the multiphasic screening 
facility have direct application to indus- 
trial audiometry. They support the use of 
pure tone audiometry for obtaining defini- 
tive threshold definition on large numbers 
of adults. By utilizing group testing pro- 
cedures, less than 2 percent of the total 
population failed the hearing check be- 
cause the test procedure (automatic audi- 
ometry) could not be understood. Prob- 
ably similar, if not better results, could be 
obtained through manual audiometry. 



Fig 4. Incidence of screening audiograms 
consistent with noise induced hearing loss. 


The four years of experience also point- 
ed out another basic fact. For audio- 
metrics to be valid, ie, meaningful to safety 
engineers and medical directors, motiva- 
tion and training of the technician must 
be maintained and supervised. Further- 
more, reduction of ambient noise in the 
test environment is an absolute must. 
During the early phases of the screening 
project, the abnormal audiogram failure 
rate was as high as 30 percent. But when 
controls involving the above were insti- 
tuted, the rejection rate fell to 11 percent. 
Certainly, pure tone audiograms, once ob- 
tained, can and do serve the conservation 
program. The periodic monitoring audio- 
grams performed thereafter will have sig- 
nificant meaning if there is no question 
about reliability. 

References 

1. Department of Labor, Part II, Occupational Safety 
and Health Standards. Federal Registrar vol. 36, No. 105, 
May 29, 1971 

2. Barbaccia JC: Health maintenance and chronic dis- 
ease. Bull Med Fac 27 :31-39, 1968 

3. Istre CO, Barbaccia JC : Hearing results in multi- 
phasic screening. Arch Otolaryngol 91:262-272, 1970 

4. Istre CO, Hamrick JT, Cherry WA: Screening 

audiometry: The use of speech frequency averaging in a 
multiphasic health screening project. J La State Med Soc 
124:1-6, 1972 


January, 1974 — Vol. 126, No. 1 


7 



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Subacute Sclerosing Panencephalitis: A Review 

• Much has been learned about SSPE in the past decade, and though 
it is not common in occurrence it is of current interest as a "slow 
virus" infection. It affects children in the South predominantly and 
is an important consideration in the differential diagnosis of degen- 
erative brain disease in the child. 

MARY ANDRIOLA, MD 
New Orleans 


CUBACUTE sclerosing panencephalitis 
^ (SSPE) was described in 1933 by 
Dawson/ - in 1939 by Pette and Doring® 
and in 1945 by Van Bogaert^ as sep- 
arate pathological entities. Even earlier 
reports may be present in the literature 
as the various types of encephalitis were 
not well distinguished nor identified eti- 
ologically. In the 1950s, it became ap- 
parent that the clinical and pathological 
features of these variously described 
encephalitides were very similar and 
represented the same disease.^ The eti- 
ological agent was felt to be a virus but 
its identity remained elusive. 

Rapid gains were made in the 1960s 
when electron microscopy of SSPE brain 
tissue revealed myxovirus-like parti- 
cles;® serum and CSF of affected pa- 
tients were found to contain high titers 
of measles antibody;^ measles virus was 
isolated from the brain of a patient with 
SSPE in 1969 and measles virus anti- 
gens were identified by immunofluo- 
rescence in cells of the cerebrospinal 
fluid of four patients with SSPE.“ The 
infectious agent has been transmitted 
from affected patients to ferrets^^ ^nd 
most recently to hamsters.^® Suppressed 
measles virus has been recovered from 
lymph node biopsies of patients with 
SSPE suggesting involvement in non- 
nervous tissue. Antiviral agents such 
as amantadine and 5-bromo-2 dioxyuri- 
dine^®-^® have not been successful in sig- 
nificantly altering the downhill course 

From the LSU School of Medicine, Department 
of Neurology and Pediatrics, 1542 Tulane Ave- 
nue, New Orleans, Louisiana 70112. 

Bibliography will be furnished on request. 


of the disease. The greater recognition 
and awareness of the features of the 
SSPE probably account for the apparent 
increase in incidence of the disease in 
the last five years.^^ 

SSPE is mainly a disease of childhood 
and adolescence. Recently compiled sta- 
tistics^^-^® revealed a striking ratio of 
boys:girls affected of 5:1. Affected in- 
dividuals were predominantly boys born 
in rural areas with over 50 percent com- 
ing from the southeastern United States. 
In most instances the disease develops 
several years after the measles exan- 
them and/or after having received mea- 
sles vaccine. Patients acquiring SSPE 
after measles vaccination may, of 
course, have previously had a natural 
infection. The attenuated live virus used 
for vaccination has not definitely been 
linked to SSPE. It is not clear how or 
why the measles virus remains latent in 
the brains of patients who subsequently 
develop SSPE or why in just a minority 
of persons it becomes activated despite 
the presence of high serum and CSF 
antibody titers. Gerson and Haslam^® 
have presented evidence of subtle immu- 
nologic abnormalities, both cellular and 
humoral, in four patients with SSPE; 
and further investigation along this line 
may allow identification of susceptible 
individuals. 

The disease usually has an insidious 
onset consisting of personality changes, 
behavior problems, mental dullness, and 
falling school grades. Eventually the 
patient will exhibit a frank dementia 
plus loss of speech. These mental 
changes are usually accompanied by 


January, 1974 — Vol. 126, No. 1 


9 


SSPE— ANDRIOLA 


increasing clumsiness progressing to a 
frank ataxia. Muscle tone is usually in- 
creased to spasticity, and the patient 
may exhibit decorticate posturing. 

Seizures usually occur during the 
course of the disease and on occasion 
may be the presenting sign; these may 
be major or minor motor or more typi- 
cally myoclonic. Myoclonic jerking of 
the extremities adds to the patient’s 
clumsiness. With jerking of the entire 
body, the patient may frequently fall 
to the floor suddenly, making locomo- 
tion impossible. 

Visual difficulty can be a presenting 
complaint. Decreased visual acuity may 
be due to a degenerative lesion of the 
macula, cortical blindness or visual in- 
attention as the dementia progresses. 
Nystagmus, secondary to blindness or due 
to primary involvement of the brain 
stem, is seen. Occasionally papilledema 
or optic neuritis leading to optic atrophy 
is noted. 

In the final stages the patient is blind, 
mute and incontinent with little volun- 
tary movement. Swallowing becomes 
difficult and weight loss is apparent. 
Myoclonic jerks may cease. Tempera- 
ture regulation may become impaired, 
and high fevers have been recorded 
without apparent infection. Most pa- 
tients die within two years after the 
onset of the disease. 

Almost all patients with SSPE dem- 
onstrate a Lange paretic type colloidal 
gold curve which reflects an elevation 
of the CSF gamma globulin. The serum 
gamma globulin is usually normal and 
is not the source of this increased 
gamma globulin. Evidence points to its 
local synthesis in the brain. 

There are few diseases causing an 
elevated CSF gamma globulin in the 
presence of normal CSF total protein 
and normal serum gamma globulin mak- 
ing this an extremely useful test for the 
diagnosis of SSPE. Multiple sclerosis 
and chronic CNS syphilis also cause ele- 


vation of CSF gamma globulin but can 
be differentiated on clinical grounds. 

The remainder of the CSF findings is 
usually normal in SSPE, though there 
may be a minimal elevation of mono- 
cytes. 

The “classical” EEG findings in this 
disorder were first described in 1949 
by Radermecker.2<5 Although not always 
present at every stage of the disease or 
in every patient, the “classical” EEG 
abnormality when recorded is helpful 
in confirming the diagnosis or perhaps 
in even suggesting it. 

The waking background activity be- 
comes slow and irregular, and high 
voltage bilateral synchronous bursts of 
sharp wave activity occur at fairly reg- 
ular intervals throughout the record. 
The bursts are less than a second in 
duration and may recur every four to 
ten seconds. These are less well seen 
during sleep, and in the early course 
of the disease do not always occur at 
regular intervals. Myoclonic activity may 
be associated with the bursts of sharp 
activity. As the disease progresses, the 
record becomes flatter and the charac- 
teristic bursts may disappear.^" 

The measles titers in the serum and 
CSF of the majority of affected patients 
are greatly elevated. An elevated ru- 
beola titer is not diagnostic of SSPE, 
but its elevation in the CSF long after 
a natural infection with measles virus 
strongly suggests SSPE. The exact 
dilutions depend on the laboratory and 
the method of preparing its antigen. 

Brain biopsy may be performed on 
a patient if tissue confirmation is felt 
necessary for diagnosis. The typical 
findings are: a) perivascular collections 
of monocytic inflammatory cells in both 
grey and white matter; b) degeneration 
of neurons which may contain Type A 
inclusions in either the nucleus or cyto- 
plasm; and c) varying amounts of gliosis 
in either grey or white matter.-" 

In the presence of a characteristic 
clinical course, with “classical” EEG 


10 


J. Louisiana State M. Soc. 


SSPE— ANDRIOLA 


findings, elevated CSF gamma globulin 
and elevated measles titers, a brain 
biopsy is not necessary to establish the 
diagnosis. 

Summary 

SSPE is a degenerative brain disease 
of childhood recently demonstrated to 
be related to a slow virus infection of 
the CNS with measles. The typical 
clinical manifestations consist of de- 
mentia, personality changes, myoclonic 


jerks, ataxia, spasticity and blindness 
with a fatal course of several months 
to several years. Laboratory studies 
reveal an elevated CSF gamma globulin, 
elevated measles antibody titer in the 
CSF and serum, and typical EEC pat- 
tern. 

Though much progress was made in 
the last decade on the disease in regard 
to etiology and diagnosis, no successful 
therapy is yet available. 



January, 1974 — ^Vol. 126, No. 1 


11 



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($100 per person as deposit) 

NAME 

ADDRESS 

CITY 

STATE ZIP 

PHONE 




dical Grand Roun 

from 

Touro Infirmary 


Pulmonary Suppuration 


Edited by SYDNEY JACOBS, MD 
New Orleans 


Dr. Pete Levine A 48-year-old 
white man with a 21-year history of 
cough and production of purulent spu- 
tum was admitted to Touro because for 
three weeks he had been weak, extreme- 
ly dyspneic and had been producing 
copious quantities of thick greenish spu- 
tum. When only 12 years old, he had 
the first of a series of bouts of pneu- 
monia. At age 14, he began to smoke 
cigarettes; and before he stopped smok- 
ing 11 years ago, his record was 48 
pack-years. When 27, he noted dyspnea 
on exertion, an increasingly severe han- 
dicap which four years later led to hos- 
pitalization and the initial diagnosis of 
bronchiectasis. Antibiotics were started 


Intern, Touro Infirmary. 


and have been taken almost continu- 
ously since then. At 36, he had to retire 
from work in the oil fields. When first 
seen here at age 40, he was producing 
two to three cups of purulent sputum 
daily. For eight years, he has been dis- 
abled ; four years ago, polycythemia was 
noted. It has required occasional phle- 
botomy. Pedal edema began last year. 
He was hospitalized twice last year with 
pneumonia, and each time a Pseudo- 
monas was isolated from the sputum. 
His only known allergies are to pollens 
and household dust, and he knows of 
no exposure to inhalational irritants. Of 
his four member sibling group, one has 
emphysema and one has asthma. 

He was found to be a well developed, 
heavyset white man in mild respiratory 


January, 1974— Vol. 126, No. 1 


13 




MEDICAL GRAND ROUNDS — Touro Infirmary 


distress with coarse rales over the left 
lung base, 1+ pitting edema in ankles 
and feet, mild clubbing of fingers and 
toes and hepatomegaly. The hematocrit 
was 56 percent. Arterial blood gases 
showed respiratory acidosis with mild 
hypoxemia, while pulmonary function 
tests showed decrease in vital car>r»city 
(VC), maximal ventilatory volume 
(MW) and forced expiratory volume 
(FEV) at one second. These data were 
interpreted to indicate chronic bronchi- 
tis and emphysema with some degree of 
reversibility of airway obstruction after 
use of bronchodilators. Treatment has 
consisted of an initial phlebotomy, daily 
therapy with IPPB and an ultrasonic 
nebulizer, postural drainage, steroids 
and continuous antibiotics. 

I have four questions : 

1) Why did his distress begin so 
early in life ? 

2) What form of treatment might 
have been effective if applied years 
ago ? 

3) How can this man’s persistent 
lung infections be treated now? 

4) What are the management with 
and the implications of continuous long- 
term antibiotic therapy? 

Dr. Masako Wakabayashi: The 

1965 chest x-ray shows overinflated 
lung fields, sparse vascular shadows, 
flattened diaphragm and bilaterally 
prominent hilar areas. The current film 
shows scattered small rounded densities 
with air-fluid levels suggesting bronchi- 
ectasis. 

Mrs. Sandi Mantz:^'^) The patient was 
born in rural Louisiana. His early life 
was marked by deprivation. His mother 
died in childbirth ; and he was only 8 
years old when his father died. He was 
reared by an aunt and uncle who died, 
as did several siblings and cousins, be- 
fore he was a teenager. He exhibits 

Second year radiology resident, Touro In- 
firmary. 

Clinical counselor. Social Service Depart- 
ment, Touro Infirmary. 


deep feeling for his wife who regards 
him as the head of the household, 
although she must make the major deci- 
sions. Having only a sixth-grade formal 
education at age 15, he lied about his 
age and enlisted in the army with his 
favorite cousin during World War II 
and served five years overseas. He re- 
turned to work overtime on an oil rig 
at taxing labor despite his doctor’s 
warning about failing health. He 
earned a high school diploma by study- 
ing bookkeeping at night classes but was 
forced to abandon this 11 years ago. 
Because he calls assistance “charity,” he 
used up all his savings before applying 
for Social Security benefits and a vet- 
eran’s pension. He will not accept help 
from his children. Deprived of hunting 
and fishing, he works around the house, 
cooks and visits. Literally, frustration is 
the story of his life. 

Mrs. Nora Spencer: A year ago, he 

eagerly participated in our classes for 
emphysematous patients learning dia- 
phragmatic breathing, how to use the 
diaphragm for coughing, how to walk 
stairs with minimal exertion and how 
to use boards for postural drainage. 
His wife was taught to do cupping. 

Dr. Sydney Jacobs: When patients 
are merely told “come back in two 
months,” they may not return ; but when 
involved in an active treatment pro- 
gram, they are much more likely to 
return. 

Dr. Melville Stemberg:<^^ This man, 
with normal levels of serum alpha-one 
antitrypsin and with no family history 
of lung disease, was completely inca- 
pacitated at age 36. In 1965, he gave a 
history of chronic cough with recurrent 
superimposed respiratory infections. 


Supervisor, Outpatient Clinic Department, 
Touro Infirmary. 

Chief, Department of Medicine Touro In- 
firmary; Clinical professor of medicine, Tulane 
University School of Medicine. 

n) Clinical professor of medicine, Tulane Uni- 
versity School of Medicine. 


14 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Touro Infirmary 


The sputum volume at first did not 
suggest bronchiectasis; but now he pro- 
duces 280-300 cc of sputum per day. 
Obviously, he has bronchiectasis. 

A man who smokes two and a half 
packs of cigarettes a day provides his 
own air pollution. In 1958, he was told 
to stop smoking but didn’t until after 
he had been hospitalized four years in 
a row with pneumonia. Since 1965, he 
improved a great deal with antibiotics. 
He has changes suggestive of emphy- 
sema in the early x-rays as well as a 
reticular formation in the left lung sug- 
gesting a variant of the Hamman-Rich 
syndrome. The pulmonary function 
studies initially showed marked obstruc- 
tive disease, loss of lung volume and a 
mixture of obstructive and restrictive 
disease. 

We kept this man out of the hospital 
seven years with the use of bronchodila- 
tors, his own Bird home respirator and 
with control of infections. He has devel- 
oped polycythemia and cor pulmonale. 
With the aid of diuretics and phlebot- 
omy, his hematocrit remains lower than 
50 ; but the problem of recurrent Pseu- 
domonas infection persists. The useful- 
ness of our rehabilitation course is indi- 
cated by his observation that “I never 
knew what you meant by postural drain- 
age until somebody laid me down on 
a board and showed me how to get up 
all these gobs of sputum”. 

Dr. Jacobs: He stopped smoking ten 
years ago. He was 14 when he started 
to smoke, and we figure 48 pack-years 
of smoking. Yet, he began to develop 
signs of respiratory insufficiency at an 
earlier age than even inveterate smokers 
ordinarily do. 

Dr. Erol Turer:^^) He is sensitive to 
house dust and to pollens, and two of 
his siblings had allergic phenomena. 
Could he have evidenced respiratory 
tract allergy at an early age? 

Dr. Sternberg: This man at no time 
had clinical asthma. The United States 


(s) Intern, Touro Infirmary. 


Public Health Service Survey showed 
that 30 percent of the population of 
New Orleans suffers from respiratory 
allergy. It could be either nasal or pul- 
monary, or both. 

Dr. Lawrence Abrahams : His social 

history is suggestive of anxiety during 
an early age and thus he seems to be a 
setup for something. I can’t account for 
why the lungs were the target organ 
and why he didn’t get an ulcer or ulcer- 
ative colitis. 

Dr. Levine: What type of manage- 
ment early in the course of the disease 
could have limited the progression? 

Dr. Sternberg: I think if I had seen 
this man very early in the disease he 
would have been a good candidate for 
lung biopsy. In 1965, his pulmonary 
function was too poor for lung biopsy. 

Dr. Jacobs: Dr. Sternberg, do you 
think the manner of telling a man to 
stop smoking has anything at all to do 
with whether or not he stops? 

Dr. Sternberg: The patient who 

smokes can go through all sorts of 
things but reaches his own individual 
decision point. If at that time you say 
the right thing, he suddenly decides 
that he will quit. I find that men will 
sometimes take it almost as a dare. 
Women just don’t go for that sort of 
thing. They can but they are not going 
to prove it to you. I don’t think any- 
body ought to smoke. With patients 
who are having symptoms, I find time 
to demonstrate a series of lung sections 
showing the progression of emphysema. 
This sometimes impresses them, some- 
times depresses them and once in a 
while gets them to stop smoking. I 
never saw a cigarette-smoking doctor 
with much luck getting a patient to stop 
smoking, nor have I even once had a 
patient who could cut down gradually 
and stop. There is only one way to stop 
and that is “cold turkey”. When he 
does stop, you have to be ready to sup- 

Director, Mental Health Center, Touro In- 
firmary. 


January, 1974 — Vol. 126, No. 1 


15 


MEDICAL GRAND ROUNDS — Touro Infirmary 


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port him with a mild tranquilizer. If 
you can get him to stay off the cigarettes 
for a month, he should feel well enough 
to stay off. 

Dr. Abrahams: A very important line 
of early treatment is psychotherapy, but 
it doesn’t necessarily have to be done by 
a psychiatrist. It can be handled by an 
internist. 

Dr. Sternberg: Doctor Abrahams, 

what about hypnosis? 

Dr. Abrahams: Volpe claims that 

hypnosis gets much better results than 
ordinary psychotherapy. I believe it to 
be less valuable than stimulating a 
patient to help himself. 

If you stop him from smoking but 
he then goes into a depression and kills 
himself, you haven’t helped the patient. 
Better a live case of bronchiectasis than 
a suicide. 

Dr. Sternberg: I have never seen any- 
body cured of smoking with the benefit 
of hypnosis. 

Dr. Levine: Questions three and four 
go together. How can this man’s per- 
sistent lung infections be treated now, 
and what is the management of con- 
tinuous long-term antibiotic therapy and 
the implications thereof. 

Dr. Carlos Alfaro: Does the contin- 
ued use of the IPPB machine at home 
perpetuate this infection? 

Miss Mary Lou McCarron:^^^ The 
patient was taught how to clean his 
machine with a 2 percent acetic acid 
solution, and every two or three months 
it is gas-sterilized. 

Dr. Sternberg: The machines are not 
reinfecting this man. Garamycin ther- 
apy for 13 days seems to have helped 
him reduce sputum volume from 300 cc 
of thick olive green pus to 40 cc of pale 
green watery material, and his pulmo- 
nary function has definitely improved. 
Yet we haven’t sterilized his lungs; he 
is always going to have Pseudomonas. 
The only way to get rid of it is to take 

(i)Intern, Touro Infirmary. 

<j)Clinical specialist, Touro Infirmary. 

J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS—Touro Infirmary 


out the bronchiectatic segments. The 
sputum production will block airways; 
so we use the machine to open atelec- 
tatic segments of the lungs, to decrease 
the edema in the bronchi and to pro- 
mote drainage. 

Dr. Jacobs: Dr. Sternberg, when 

would we say that this bronchiectasis 
became manifest? 

Dr. Sternberg: I would say, roughly, 
three to four years ago. 

Dr. Jacobs: Well, let’s make it five 
years. just to be arbitrary about it. And 
we would say then that for 20 years 
or so he had symptoms of chronic pul- 
monary disease ; but he didn’t have 
symptoms of bronchiectasis. Only in the 
past five years or thereabouts did a 
change take place to produce bronchi- 
ectasis. We used to know bronchiectasis 
as a disease predominantly of children. 
What do you suppose brought about 
bronchiectasis in him ? This is most 
unusual. 

Dr. Sternberg: He has had recurrent 
infections and he has had emphysema 
which forms cysts in the lungs ; obstruc- 
tion is the cause of his bronchiectasis. 

This is the kind of thing you’d expect 
to see in a patient who had tubercu- 
losis years ago with destruction of the 
lung lobe. These patients tend to get 
bronchiectasis in these areas. I think 
it is a matter of degree. I think all of 
them have the danger of secondary in- 
fection ; but it’s the patient who has had 
lung destruction who tends to get bron- 
chiectasis due to that recurrent infection 
as contrasted to the usual emphysema 
that we see. 

Dr. Jacobs: In the pre-antimicrobial 
days when bronchiectasis was prevalent 
many young persons with offensive spu- 
tum became social pariahs and commit- 
ted suicide. Today with antimicrobials 
this almost never happens. 

Dr. Sternberg: Of course, continued 
antibiotic therapy in a patient with 
chronic lung disease is controversial. 
The British tend to favor using intermit- 


tent therapy during the winter season 
for chronic bronchitis patients; others 
advocate just to use it when absolutely 
indicated. In a patient who has recur- 
rent infections and has severe lung dis- 
ease, continuous antibiotic therapy 
helps. Now, this doesn’t mean always 
with the same antibiotic, but switching 
your antibiotic when there is a change 
in the condition. 

Well, he has stopped smoking com- 
pletely. His pulmonary function is bet- 
ter; but I think he probably has less 
lungs than he had when I first saw him 
in 1965. I can remember saying if we 
could keep him going five years, we 
would be doing well, and we have kept 
him going eight years. He is young 
which means that he has probably a 
pretty good heart and good kidneys. 
In fact, all of his other vital organs 
seem to be good. If we had the same 
disease in an older man with athero- 
sclerosis, the outlook would be much 
worse. 

Dr. Jacobs: Bronchiectasis occurs in 
a setting of bronchial infection, reten- 
tion of infected secretions and at times, 
of bronchial wall congenital weakness 
or abnormality. Bronchial obstruction 
is usually a prerequisite. Seventy-five 
percent of cases of bronchiectasis de- 
velop symptoms by age 5. This is 
thought to be due to frequency of re- 
spiratory tract infections in childhood 
and to the easy compressibility of the 
small bronchi by enlarged nodes or 
secretions. 

Bronchiectasis of variable degree fol- 
lows suppurative pneumonia or lung 
abscess at any age; its extent relates 
inversely to the promptness and effec- 
tiveness of the treatment of the original 
disease process. 

The most frequent cause of obstruc- 
tion is inspissated secretions forming a 
plug in a bronchus; those who fail to 
cough up such plugs may develop bron- 
chiectasis. 

Many authors have described the per- 


January, 1974 — VOL. 126, No. 1 


17 


MEDICAL GRAND ROUNDS— Touro Infirmary 


sistent infection, progressive dyspnea, 
cyanosis, clubbing and eventually cor 
pulmonale of the severest cases. Many 
patients with milder bronchiectasis may 
lose cough and sputum at puberty until 
smoker’s bronchitis sets in. 

Cigarette smoking paralyzes ciliary 
action, increases bronchial secretions, 
inflames mucous membranes, causes 
mucous-gland hyperplasia and results 
in epithelial squamous metaplasia, 
thereby, impairing adequate bronchial 
drainage. 

Dr. Levine’s questions one and two 
remind us of the historical develop- 
ment of medical concepts. When this 
patient at age 12 in 1937 had pneu- 
monia. we were just at the start of the 
sulfonamide era and weren’t capable of 
preventing the progressive lung destruc- 
tion caused by necrotizing microorgan- 
isms. When he started to smoke in 
1939. most of us were still unaware 
of the terribly harmful effects of cig- 
arette smoke on healthy, let alone dis- 
eased. lungs of adolescents. Only now^ 


has it been documented that approxi- 
mately 20 percent of smokei*s of high 
school age have evidences of airway 
obstruction. Today, we can effectively 
treat bacterial infections of the lung; 
but we still don’t know how to induce 
teenagei*s not to smoke. To answer 
questions three and four adequately, it 
is necessary to remind ourselves that 
organ failure must be treated today by 
a comprehensive program. Digitalis and 
diuretics do not, in themselves, consti- 
tute a complete treatment for congestive 
heart failure ; neither do antimicrobials 
and postural drainage suffice for pul- 
monary suppuration and airway obstruc- 
tive disease. A far-reaching program 
of pulmonary rehabilitation, such as the 
one presently offered to the patient 
herein discussed, is the best means cur- 
rently available for enhancing the 
“quality of life” of the man with se- 
verely damaged lungs. 

References 

1. Lim TPK: Airway obstruction among: high school 
students. Am Rev Resp Dis 108:986, 1973 


18 


J. Louisiana State M. Soc. 


-S 


oci oecon omic 



By LEON M. LANGLEY, JR.^ 


The Cost of Living Council has announced proposed price control regulations for the 
health industry that would allow a 4% average increase in doctors’ fees this 
year. The new regulations were to take effect on January 1 ; however, a two- 
week period for comment was allowed and certain changes could occur in the 
regulations before they become effective. In brief, the new regulations provide 
that doctoi'S, dentists and other medical practitioners would be allowed an over- 
all increase in their fees of 4%, up from the 2.5% limitation in present con- 
trols. There is a limitation of a maximum 10% fee increase for any one service 
over $10 and an increase of $1 for any service under $10. Doctors would also 
have to maintain a schedule of fees for their patients to see. 

Many Records Were Broken with the beginning of the 1973-74 medical school year. 
An all-time high total enrollment of more than 50,000 could produce 11,862 
new physicians by the end of the school year. This fall, 114 medical schools, 
the most in history, admitted approximately 13,790 first-year students, another 
record. In 1973, 932 women graduated from medical schools, and 6,098 women 
enrolled in all medical schools last year. Two new medical schools opened 
their doors this fall. They are Southern Illinois U. School of Medicine, Spring- 
field, and Eastern Virginia Medical School, Norfolk. 

Medicare Beneficiaries Will Have to Pay $84 toward their hospitalization begin- 
ning Jan. 21 instead of the current $72, the Dept, of HEW said. The increase, 
necessary because of rising hospital costs, was approved by the Cost of Living 
Council, HEW Secretary Caspar Weinberger said. 

Health Agency Reorganized — The Federal Health Resources Administration, one 
segment of what formerly was HEW’s Health Services and Mental Health 
Administration, has been reorganized into three bureaus: the Bureau of Re- 
search and Evaluation, Bureau of Health Resources and Development, and the 
National Center for Health Statistics. HRA Administrator Kenneth M. Endicott, 
MD, said the activities of the Bureau of Health Manpower Education, Commu- 
nity Health Service, Regional Medical Programs, and the Health Care Facilities 
Services will be placed in three new bureaus. 

Noting a Decline in the number of defaulted loans, the AMA-ERF Student Loan 
Guarantee Fund’s 1973 mid-year report shows that $225,256 was paid to banks 
participating in the program for defaulted loans during the first six months of 
1973. During the same period in 1972, AMA-ERF repaid $325,080 to lenders. 
Since its inception in 1962, the AMA-ERF program spent $2,760,062 for 1,012 
defaulted loans. Approximately 60,000 students have defaulted on $55.2 mil- 
lion in federally guaranteed loans since 1968 and the government has recovered 
only $3.2 million, according to the Office of Education. 

Certification-of-Need Legislation has been enacted in 22 states, is pending in 6 
states, has been dropped or defeated in 11 states, has been repealed in 1 state, 
and has not been acted upon in 10 states, according to an August survey by 
the American Hospital Association. The survey also found that rate-review 
legislation has been enacted in 10 states, is pending in 5 states, has been 
dropped or defeated in 5 states, and has not been acted upon in 30 states. 
Three of those 30 states have voluntary rate-review programs. Louisiana pres- 
ently has neither certification-of-need nor rate-review statutes. 


January, 1974 — Vol. 126, No. 1 


21 


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BALTIMORE 


Health Care, Human Rights AND Government Intervention 


GARVAN F. KUSKEY, DBS 
Santa Barbara, California 


Seventeen years ago the Austrian 
economist Ludwig von Mises observed 
that the people of the United States 
enjoyed the highest standard of living 
of any people in the world; but only be- 
cause the US government embarked 
much later than the governments in 
other parts of the world upon the pol- 
icy of obstructing human enterprise 
and endeavor. The dismal results of 
government intervention in the areas 
of agriculture, education, employment, 
housing, urban renewal, mail carriage, 
and transportation, to name but a few, 
are a matter of record. Today it ap- 
pears that the US government is on the 
verge of a massive intervention into 
the practice of dentistry and medicine, 
because of an alleged “health crisis” in 
America. This impending action, which 
has the blessing of both political par- 
ties as well as elements in the ADA 
and AMA, has been given the name 
National Health Insurance, a political 
euphemism for socialized medicine. 

When exposed to the ample body of 
evidence which documents the fact that 
no such crisis exists, supporters of gov- 
ernment medicine generally point out 
that there are, nonetheless, still those 
who are not benefiting from our health 
care system. For example, in our own 
area of dentistry we are told by our 
liberal and conservative colleagues alike 
of the millions of cavities that are going 
unfilled in the mouths of the deprived 


Dr. Kuskey has offices in Santa Barbara, Cali- 
fornia. His article is reprinted by permission 
from the Journal of the California Dental Asso- 
ciation, July, 1973. Information regarding refer- 
ence material for this article may be obtained 
from the above or from the office of the Journal 
of the Louisiana State Medical Society. 


and disadvantaged. The fact that there 
are also millions of unfilled cavities in 
the mouths of affluent suburbanites 
does not give them pause; we are still 
told that our free-enterprise system of 
health care, good as it is, must be 
changed, even drastically, in order that 
the medically indigent receive the care 
to which they are entitled. (For example, 
95 percent of all dentists examined in 
the oral health screening panel by Dr. 
Sherwin Z. Rosen at the October 1972 
ADA convention in San Francisco had 
dental disease ; 60 percent had peri- 
odontitis. This unusually high inci- 
dence of pathology can hardly be attrib- 
uted to lack of education or financial 
resources. What it does tend to confirm 
is that many Americans, rich and poor, 
educated and uneducated, choose to allo- 
cate their time and resources to activi- 
ties other than achieving proper oral 
health. A government program of either 
treatment or education is unlikely to alter 
this situation. — JADA 86:743, April, 
1973). 

Foreign Experience 

At this point, discussions of socialized 
medicine usually devolve into pragmatic 
considerations of whether or not this or 
that program of government health care 
will work. From the abundant evidence 
available which describes the experi- 
ences in other countries which have 
adopted various plans of socialized med- 
icine, it would appear that government 
medicine in any form is more costly 
than privately rendered care, is ineffi- 
cient in its delivery and often militates 
against the very persons it is designed 
to help. We commit a serious error, 
however, if we focus all of our atten- 


January, 1974 — ^VOL. 126, No. 1 


23 


GUEST EDITORIAL 


tion upon these pragmatic considera- 
tions without first determining whether 
or not it is possible for a person to actu- 
ally possess a right to health care (or, as 
it is often more skillfully stated, a right 
to access to health care). 

Before discussing health care “rights,” 
it is necessary to first examine the philo- 
sophic underpinnings of the concept of 
rights itself. Exactly what constitutes a 
human right? Does a right come into 
existence because a legislature proclaims 
it? Can a President create human rights? 
Or a “majority”? To answer these ques- 
tions we must begin our logical progres- 
sion from the irrefutable premise that 
man exists. Since man exists as a living 
being, it can be apodictically stated that 
a human individual’s most fundamental 
right is the right to his own life. From 
the time of the Greek philosophers to the 
present, no one has stated this fact more 


concisely than the British political philos- 
opher Auberon Herbert: 

The great natural fact of each person being 
born in possession of a separate mind .and sep- 
arate body implies ownership of such mind and 
body; it will be found on examination that no 
other deduction is reasonable. Elaborating on 
this point, Herbert devastates the argument that 
“society,” the state, or anyone else has a valid 
claim on one’s person; 

If there is one thing on which we can safely 
build, it is the great natural fact that each 
human being forms with his or her body and 
mind a separate entity — from which we must 
conclude that the entities belong to themselves 
and not to each other. As I have said, no other 
deduction is possible. If the entities do not be- 
long to themselves, then we are reduced to the 
most absurd conclusion: A or B cannot own him- 
self; but he can own, or part own, C or D. 

The Right to Produce 

The right to one’s own life implies a 
major corollary: the right to engage in 
the production of values which will sus- 
tain that life. These values are accord- 



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is represented by 


GUEST EDITORIAL 


ingly the exclusive property of the in- 
dividual who produces them. If an indi- 
vidual’s property is seized from him by 
force (or threat of force) his right to 
his property does not transfer to the 
robber. This fact is not altered whether 
the robber is acting alone or is a mem- 
ber of a gang. Even if a majority of 
individuals in a given geographic area 
sanctions the robbery, the owner has not 
lost his right to his property. We can, 
therefore, posit that the right to one’s 
own life, as well as the corollary rights 
thereof, accrues to each individual quite 
independent of the will of legislatures, 
Presidents, or majorities. Rights, of 
course, cannot exist in conflict. Thus 
the right to use or dispose of one’s 
property implies a mandate to refrain 
from physical interference, or the threat 
thereof, with another individual’s right 
to use or dispose of his property. 


A Right to Health Care? 

On the basis of the foregoing we can 
now examine whether a right to health 
care can exist. Health care is a service 
provided by doctors and others to peo- 
ple who wish to purchase it. A person 
in need of health care (or, for that mat- 
ter, food, clothing, housing, transporta- 
tion, or recreation) does indeed possess 
a right to seek to enter into a bilateral 
voluntary exchange with a health care 
provider (or grocer, clothier, builder, 
auto dealer, or travel agent). But the 
mere existence of a need for a service or 
goods does not imply a right to them. 

In current political parlance, the 
“right” to health care has come to mean 
the right to health care at the expense of 
someone other than the recipient of the 
service. There are four ways this can 
occur: 1) by the doctor voluntarily giv- 
ing his services to the patient; 2) by a 



Puts comfort 
in your prescription 
for nicotinic acid 


GUEST EDITORIAL 


charitable individual or organization 
voluntarily donating the cost of the pa- 
tient’s treatment; 3) by the patient or 
his agent physically , coercing the doctor 
into providing the service; or 4) by the 
patient purchasing the service with 
funds seized from others in the form 
of taxes. It should be immediately ap- 
parent that while the first two examples 
constitute morally proper transactions, 
the latter two constitute blatant abroga- 
tions of genuine rights: either the doc- 
tor owns his own life or the patient 
owns it; and, as the fourth case, either 
the individual taxpayers own their own 
lives, or the patient owns them. The 
absurdity of a person in need of health 
care owning a part of a doctor’s life, 
or a part of anyone else’s life, has been 
well demonstrated by Herbert. 

To claim, then, that medical care is 
a right — that a man has a right to be 
cared for by somebody else — raises the 
question : What of that other some- 
body’s rights? Since rights cannot exist 
in conflict, we can arrive at no other 
logical conclusion: There exists no such 
thing as a right to health care. 

What Can Be Done 

Once we have diasbused ourselves of 
such fallacies as the existence of a US 
“health care crisis,” the “right” to 
health care, or the ability of the gov- 
ernment to deliver what the private 
sector cannot, we can get on with the 
business of trying to solve those medi- 
cal and dental problems that are soluble 
at all. For example, approximately two- 
thirds of American mortalities other than 
those attributable to the senile cessation 
of body functions are due to diseases 
known to be caused or exacerbated by 
such factors of 'personal choice as alcohol, 
tobacco, or overeating; or due to acci- 
dents. What government program, short 
of outright imprisonment, could change 
this? 

Those who advocate NHI frequently 
attempt to buttress their position by 


pointing at the catastrophic illness that 
bankrupts a family, or the seemingly 
unresolvable “lifeboat” situation where- 
in a mythical doctor in a sparsely popu- 
lated rural county demands an out- 
rageous fee to save the young widow’s 
life. Although it is often assumed that 
only the government can resolve these 
classical health dilemmas, this assump- 
tion is clearly in error. For example, it 
is an accepted norm in our society to 
insure one’s home against fire. Does not 
common sense dictate a similar practice 
with regard to one’s own health? Cata- 
strophic health insurance is readily 
available for the daily price of a pack- 
age of cigarettes. For the family that 
is so destitute that it cannot afford even 
the most modest health insurance pre- 
mium, there exists in the United States 
today an abundance of private chari- 
table organizations which offer all 
forms of succor, including health care, 
to the poor. It is worthy of note that 
they exist in spite of confiscatory taxa- 
tion on the private incomes that provide 
the bulk of their support. The “life- 
boat” health situations are in actuality 
so rare that they cannot be used with 
any statistical validity in justifying a 
change in our present system of health 
care delivery. 

Government-caused Problems 

Many of the ills that affect the health 
of the average American are due to 
poor diet and inadequate housing; not 
faulty health care. Those doctors who 
are willing to go beyond the confines 
of their clinical practices to relieve the 
distress of the medically indigent should 
examine the extent to which poverty — 
and the consequent inability to purchase 
sufficient health care, or the inability 
to live in a healthier environment — are 
the direct result of prior government 
intervention into the economy. Carson, 
Hazlitt, Anderson, and others describe 
at length how many of the “disadvan- 
taged” in our society are made so be- 
cause government minimum wage laws 


26 


J. Louisiana State M. Soc. 


GUEST EDITORIAL 


have forcibly disemployed them; how 
workers, particularly minority group 
members, are excluded from the labor 
market by government-protected labor 
unions ; how would-be entrepreneurs 
with little capital are denied entrance 
to many areas of business by expensive 
government licensing and government- 
created monopolies; how many of the 
poor are tom out of their modest homes 
and pushed into unhealthy slums to 
make room for the plush shopping 
malls, luxuiy highrise apartments and 
freeways of government “urban re- 
newal” projects; and how inadequate 
diets are in part the result of govern- 
ment taxes which comprise almost half 
of the purchase price of food. It flies 
in the face of reason to suggest that 
medical indigency induced by previous 
government interventions into the econ- 
omy be ameliorated by further govern- 
ment intrusion which will of itself addi- 
tionally pauperize those who are taxed 
to pay for the new health programs. 

Summary and Conclusions 

While there are indeed some Ameri- 
cans who are not in a financial posi- 
tion to fully utilize all of the benefits 
of our free-enteiq)rise health care sys- 
tem, this in no way indicated the exist- 
ence of a “health care crisis” in this 
country. Their ability to purchase 
health care would be greatly improved, 
however, if they could obtain relief 
from the onerous burden of govern- 
ment taxation they are enduring. 

The establishment of a system of 
socialized medicine is justified by its 
advocates because they feel some Amer- 
icans have a “right” to health care at 
the expense of others. Some feel that 
the government could provide better 
health care than do private practitioners 
and private hospitals. Such justification 
is clearly in error, since there exists no 
such thing as a “right” to health care, 
nor is there a shred of evidence to indi- 
cate that the government could perfomi 
any better in the area of health care 


than it has in the areas of housing, 
education, agriculture and other areas 
where its failures have been monumen- 
tal. In fact, government Medicare and 
Medicaid programs are among the prin- 
cipal reasons for today’s rising health 
care costs and clogged health facilities. 

Since a medical millennium is an im- 
possibility under any economic system, 
there will always be that small number 
of individuals who are unable to obtain 
the full services of the health care sys- 
tem. It is understandable, commend- 
able, and in the American tradition to 
want to extend a helping hand to them. 
But does not prudence, as well as com- 
passion for the overwhelming majority 
who fall within the existing system, 
demand that the rational critic of US 
health care spend his time trying to 
improve our system, rather than trying 
to impose radical change such as Na- 
tional Health Insurance would bring? 

If the government succeeds in fasten- 
ing socialized medicine upon the people 
of the United States, the quality and 
quantity of our health care will cer- 
tainly decline. This will give future his- 
torians the unpleasant task of reporting 
that von Mises’ observation of 1956 had 
become invalid : that the US govern- 
ment, at least in terms of health care, 
had succeeded in adjusting the US 
standard of living doionivard to match 
that of the rest of the world. 





January, 1974 — ^Vol. 126, No. 1 


27 


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The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


TELEPHONE CONSULTATION SERVICE TO 
BE AVAILABLE TO DERMATOLOGISTS 

Dermatologists seeking help with problem 
cases will have access to expertise of colleagues 
via telephone beginning in June, 1974. 

The National Program for Dermatology of the 
American Academy of Dermatology has an- 
nounced the establishment of a telephone con- 
sultation ser\dce for skin disease specialists. A 
total of 64 dermatologists, primarily from teach- 
ing centers, have volunteered to receive long 
distance phone calls during a specified period 
each week (usually one to two hours) from par- 
ticipating dermatologists. 

Ullin W. Leavell, Jr., MD, Lexington, Ky., 
Professor of Medicine in Dermatology, Univer- 
sity of Kentucky, who heads the Task Force in 
charge of the telephone consultation service, said 
“hopefully, the communications project will im- 
prove the quality of treatment as well as diag- 
nosis on difficult cases.” 

A roster of dermatology experts available for 
consultation (with phone numbers and hours of 
availability) will be distributed to practicing der- 
matologists prior to the June, 1974, starting 
date. Dr. Leavell said that the service will be 
limited to skin diseases specialists at the offset; 
however, if the consultation arrangement works 
out, it may be expanded to allow other medical 
specialists to phone for advice. 


1974 ANNUAL MEETING 

It is not too early to start mak’ng your plans 
for the 1974 Annual Meeting of the Louisiana 
State Medical Society which will be great. It will 
be held in Lake Charles May 5-7. 

Dr. Walter Moss and Dr. J. Y. Garber, Co- 
Chairmen of the Committee on Arrangements 
for this meeting have been most active, in co- 
operation with the other doctors of Lake Charles, 
in making plans for this meeting and from all 
indications nothing will be spared in efforts to 
make our meeting this year one that will be long 
remembered for the constructive business trans- 
acted, its educational value and the social activi- 
ties enjoyed. 

The first official function will be the dinner 
for past presidents of the Society which will be 
held on Saturday evening. May 4. 

On Sunday morning. May 5 the House of Dele- 
gates will convene at nine o’clock. The second 
session of the House will be held on Tuesday 


morning. May 7 and is expected to adjourn by 
Noon on that day. 

A luncheon for members of the House of Dele- 
gates will take place on Sunday and the mem- 
bership luncheon, which will include a panel dis- 
cussion, will be scheduled for Monday. The 
LAMPAC luncheon will be held immediately fol- 
lowing the Tuesday session of the House of 
Delegates. 

An outstanding scientific program has been 
planned consisting of discussion of telemetry and 
computer applications in medicine, a talk by an 
astronaut, a presentation on action in court and 
a panel discussion on infectious diseases. 

Social activities will include a party for the 
executive committees of the State Society and 
the Auxiliary on Saturday evening, a Cajun 
party for all members and guests on Sunday 
evening and the president’s dinner on Monday 
evening. 

It is hoped that all members will mark their 
calendar for the Annual Meeting dates and make 
plans to attend. The headquarters motel will be 
the Sheraton Chateau Charles, and reservation 
forms and additional information will be sent to 
all members during January. 


PHYSICIAN-PATIENT COMMUNICATION 
AND COURT RULES 

Legislation passed by the Senate recently will 
postpone the effective date of a new code of 
evidence to be established in Federal courts 
across the country. 

The new rules will abolish the physician- 
patient privileged communication in court ex- 
cept communication during psychotherapy. 

A Committee of the Judicial Conference of 
the United States developed the new rules and 
they were submitted to the Congress by the 
Chief Justice under the judicial code. Congress 
then has 90 days to consider the changes and if 
there is no objection they go into effect. How- 
ever, several members of Congress have asked 
for a complete study of the proposed changes. 
The Senate has delayed their taking effect until 
the end of the session or until Congress has 
agreed to them. 

AMA has testified regarding their position on 
the changes and has called for the continued 
recognition of the present physician-patient pri- 
vilege. It was indicated in testimony before the 
House Committee on the Judiciary and the Sen- 


January, 1974 — VOL. 126, No. 1 


29 


ORGANIZATION SECTION 


ate Subcommittee on Separation of Powers that 
disclosure of personal information could be con- 
sidered harmful and embarrassing to patients. 


1973 PM A FACT BOOK 

Rising research costs, price stability and rapid 
growth continue to characterize the U. S. pre- 
scription drug industry. Its worldwide sales 
reached $7.4 billion in 1971, an increase of 
more than 8 percent over 1970, and are estimated 
at more than $8 billion for 1972. 

Detailed information on these and other as- 
pects of the industry are outlined in a recently 
prepared publication by the Pharmaceutical Man- 
ufacturers Association. 

The 1973 edition of the PMA Fact Book, in 
addition to information on sales, price levels 
and research and development, provides facts on 
the industry structure, employment, quality con- 
trol, safety and availability of prescription drug 
products, international operations and the health 
care industry in general. The 101-page book, 
including charts and tables, glossary, appendix 
and bibliography, uses data from published sta- 
tistics available in late 1972. 

Following are some highlights of the 1973 
Fact Book: 

— The 1971 Wholesale Price Index for pre- 
scription drugs declined 2 percent from the pre- 
vious year, while the wholesale index for all 
commodities rose 3.2 percent in 1971. 

— During the period 1967 through 1971, the 
Consumer Price Index (retail) for Rx drugs in- 
creased only 1.7 percent, compared with a 24 
percent increase for all items. Within a one- 
year period, the index for prescription medicine 
rose less than one-half of one percent. 

— The average retail prescription charge was 
$3.92 in 1971, up from $3.22 in 1961. When 
adjusted for the increase in package size, how- 
ever, the average prescription per dose or tab- 
let has actually declined by three percent since 
1961. 

— Research and development expenditures bud- 
geted for 1972 totaled $728 million, 6.5 per- 
cent more than the $684 million spent in 1971. 

— The top four firms in the pharmaceutical 
industry (both prescription and proprietary) ac- 
counted for 24 percent of the industry’s total 
value of shipments, with the top eight account- 
ing for 41 percent. This degree of concentration 
is well below that of most industries. 

— Worldwide employment in firms headquar- 
tered in the U. S. (including overseas subsidi- 
aries) reached 240,620 in 1971. 

— In 1971 there were 21,725 people em- 
ployed in research and development, with the 
scientific and professional staffs comprising over 
half of the total R&D manpower. 

— Of the 898 new single chemical entities in- 


troduced to the U. S. market since 1940, about 
two-thirds originated in the U. S. Almost half 
of the world’s leading pharmaceuticals marketed 
since 1950 were discovered in the U. S. 

— In 1971 there were only 14 new single 
chemical entities introduced in the U. S. market. 

This decline in the number of new en- 
tities in the past decade, PMA explained, 
“may be due in part, to a trend in research 
to seek major breakthroughs for treatment 
of the more intractable diseases. However, 
the increased time needed in testing and 
in meeting the regulatory requirements of 
the Food and Drug Administration is an 
important factor.” 

Among other data in the Fact Book: Over- 
seas volume of U. S. pharmaceutical firms to- 
taled $2.4 billion in 1971, an increase of over 
$200 million from the previous year; only $125 
million of this total consisted of direct exports 
from the U. S. 

— In 1971 consumers in the United States 
spent $4.3 billion for prescription drugs, ac- 
counting for 8.3 percent of the consumer’s med- 
ical care dollar. 

Single copies of the Fact Book are available 
from the PMA Public Relations Division. 


EXPERTS GIVE THE BRUSH TO 
SOME HAIRY TALES 

Hair, a substance cloaked — or rather capped — 
in myth and mystery, was the subject of a recent 
conference sponsored by the American Medical 
Association’s Committee on Cutaneous Health and 
Cosmetics. Items of discussion among physicians, 
research scientists and others included: 

Brushing and Combing. If you brush your 
hair 100 strokes a day to make it “healthy,” you 
are deluding — and possibly denuding — yourself. 
“Brush and comb to groom, not to treat,” ad- 
vised Dr. Norman Orentreich of New York, de- 
veloper of the hair transplant. “There is good 
evidence that it causes hair loss, especially comb- 
ing, due to the force applied in repeated strokes.” 
Dead or Alive? According to Dr. William Mon- 
tagna of Beaverton, Oregon, despite its luster on 
some heads, the plain (bald, if you will) truth 
is that hair is not alive but dead as rope — even 
when it is being manufactured in the follicle — 
and you can’t “feed” it with protein or lemons 
or anything else. 

Washing. Does it contribute to baldness? How 
often should one shampoo? The answer to the 
first question, says the AMA committee, is a 
flat no. And in reply to the second, it depends 
on what type of hair one has. “Very oily hair 
can be shampooed daily, said Mrs. Linda Allen 
Schoen of the Committee staff. “With dry hair, 
you can go 4 to 7 days if there is no unusual 


30 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


exposure to dirt. More frequent washing of dry- 
hair can make it break.” 

Mission Impossible. Science can’t identify peo- 
ple from hair, despite what detective stories say. 
Not only does ha^'r from one nerson differ from 
that of another, hairs growing side by side on 
the same head can differ greatly in size and 
appearance. Even sections of a single hair can 
differ greatly. 

The Conference was by no means able to tell 
everything there is to know about hair. Some 
things remain unknown. Like why hair goes 
through an anagen (growth) phase and a telogen 
(resting) phase. Or why the length of the rest- 
ing phase increases with a person’s age. Or, as 
men have wondered from time immemorial, how 
hair can be restored once it’s gone! 


HYPERTENSION: THE NEGLECTED 
DISEASE 

More than half of the Chicagoans who have 
hypertension don’t know it, and four out of ten 
who do know aren’t being treated for it. This 
is doubly unfortunate, since early detection and 
treatment of high blood pressure lessen the prob- 
ability of heart disease and stroke. 

Thus, in spite of recent publicity on the bene- 
fits of early treatment, findings from the Chi- 
cago survey showed no improvement over results 
of a nationwide Public Health Service survey 
conducted in 1960-62. If anything, the recent 
survey indicates that fewer people are currently 
being treated for hypertension, although the in- 
cidence of the disease has not decreased. 


People most likely to have high blood pres- 
sure are male, black and over 45 years of age. 

The authors conclude that “our nation has a 
sizeable, unresolved problem of control of hyper- 
tension, and an urgent need to implement effec- 
tive approaches for the management of this seri- 
ous mass disease.” 

In early 1973, the Louisiana Heart Association 
put on a hypertension detection campaign 
in the Greater New Orleans area in a similar 
manner to the measles and polio immunization 
camnaigns. All physicians in the Greater New 
Orleans area were asked to participate with their 
sphygmomanometers and stethoscopes. 

These are the conclusions regarding high blood 
pressure drawn from a four-year developmental 
program conducted by the Chicago Heart Asso- 
ciation to screen for the risk of coronary heart 
disease and published in the October 30 issue of 
Journal of the American Medical Association. 

Of the 22,929 industrial employees who vol- 
unteered for the free tests, 4,625 were found 
to be suffering from high blood pressure, which 
for the purposes of the study was considered 
to be above 95 diastolic and/or 160 systolic. The 
majority (58.9 percent) were not being treated 
and denied having been told of the disease prior 
to this screening, although most had seen their 
doctors in the preceding two years. The authors 
of the study speculate that the disease either 
was not diagnosed or that the patients simply 
were not told by their doctors that they had 
high blood pressure. 


January, 1974 — Vol. 126, No. 1 


31 


Have you ever held a meeting 
between a Riverboat and a Southern Plantation? 



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meeting rooms to end 
them all ! 

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30 meeting rooms and 
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Plus a Grand Ballroom 
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32 


J. Louisiana State M. Soc. 



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CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every month 


Calcasieu 

Fourth T uesday ot every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday ot every month 

Baton Rouge 

Jackson-Lincoln- Union 

Third Tuesday of every month 
except summer months 

Jefferson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every ether month 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First NA/ednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

Independence 

Terrebonne 

Third Monday of every month 

Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday of every month 



NEW AMA PROGRAM TO IMPROVE 

EARLY HEALTH CARE FOR CHILDREN 

The American Medical Association is sponsor- 
ing a series of meetings at the national, state 
and local levels to enhance early screening, diag- 
nosis and treatment of children under the Medi- 
caid program. 

The AMA, through its Committee on Health 
Care of the Poor, will be responsible for launch- 
ing this program in an effort to improve health 
care for children in low-income areas. 

The AMA, along with other health disciplines, 
will identify and recommend solutions to be de- 
veloped. The recommendations will then be tested 
in a pilot demonstration program at a local site 
to be designated. Information developed through 
the AMA program will be published in a report 
that will be available to others involved in the 
problem. 

The program will be carried out with a $25,000 
grant from the U.S. Department of Health, Edu- 
cation and Welfare. 


GLAUCOMA SURGERY SYMPOSIUM 

THE UNIVERSITY OF TEXAS HEALTH 
SCIENCE CENTER AT HOUSTON 
MEDICAL SCHOOL 

In the past three years, several distinctly 
different surgical glaucoma procedures have 
been developed, and each of the speakers has 
had experience with one of these new methods. 
The Symposium will consist of presentations of 
these new procedures combined with a general 
panel discussion of problem cases. 

The speakers will be Dr. John Lynn, Dallas, 
Texas; Dr. Richard Simmons, Boston, Massachu- 


setts; Dr. William Layden, Tampa, Florida; and 
Dr. Robert Stewart, Houston, Texas. 

Registration is $25.00 with no charge for resi- 
dents. 

For further information, contact The Office 
of the Director, The University of Texas Health 
Science Center .at Houston, Division of Continu- 
ing Education, Post Office Box 20367, Houston, 
Texas 77025. 


THE INDUSTRIAL MEDICAL ASSOCIATION 

Physicians who are interested in providing 
medical services to business organizations on a 
part-time or full-time basis may obtain a copy 
of the Employment Referral Service Bulletin 
published monthly by the Industrial Medical As- 
sociation. Openings for positions throughout the 
country are listed therein. 

For a free copy, write the Industrial Medical 
Association, Employment Referral Service, 150 
North Wacker Drive, Chicago, Illinois 60606. 


GREATER CARE URGED IN 
GIVING POLIO VACCINE 

Many supposedly immunized children actually 
aren’t protected .against all three types of polio 
because of careless administration of the vac- 
cine, says a report in the October issue of the 
American Journal of Diseases of Children. 

A study made on more than 500 children in 
low income areas in six Illinois communities re- 
vealed that only one-third of those with three 
doses of oral vaccine actually were immune to 
all three strains of polio virus. A fourth dose 
boosted immunity level only to 40 percent. 

The study team from the Cook County (Chi- 


January, 1974 — VOL. 126, No. 1 


33 


MEDICAL NEWS 


cago) and Illinois Departments of Public Health 
described practices that might account for the 
low immunity level among children who had re- 
ceived the vaccine. 

Some of these involved improper handling of 
the vaccine; using outdated material; storing un- 
opened bottles in a refrigerator instead of a 
freezer; and keeping the vaccine too long under 
refrigeration. 

Small children, unless carefully watched, some- 
times frustrate immunization efforts. They 
“squirrel-pouch” the sugar cube, later spitting it 
out. Or they palm the cube and later throw it 
away. Attendants have missed the mouths of 
tiny infants in administering drops. The vaccine 
drops have been placed on sugar cubes and then 
left in warm temperature for many hours before 
administration. Drinking of chlorinated water 
just before or after ingesting the vaccine can 
kill its immunizing impact. 


TWENTY-SEVENTH ANNUAL SCIENTIFIC 
ASSEMBLY 

LOUISIANA ACADEMY OF 
FAMILY PHYSICIANS 

The Louisiana Academy of Family Physicians 
will hold its Twenty-Seventh Annual Scientific 
Assembly at The Monteleone Hotel in New Or- 
leans on January 30-31 - February 1, 1974, it was 
announced by Dr. Frank G. Rieger of Baton 
Rouge, LAFP Secretary. The Academy’s General 
Assembly will be in session on the morning of 
January 30, with Dr, Durell Hiller of Shreveport, 
Speaker of the Assembly, as the presiding officer. 
Dr. Eli Sorkow of Lake Charles is Vice-Speaker. 

On the evening of January 30, Academy mem- 
bers and guests will be entertained by Dr. Richard 
Pullig of Clinton and Dr, and Mrs. Robert Looney 
of Lake Charles. Dr. Pullig is president of the 
Academy and Dr. Looney is president-elect. 

Formal opening exercises will be held on the 
afternoon of Wednesday, January 30 with Dr. 
Rafael Sanchez, presiding. Dr. Richard Pullig 
will preside at the scientific sessions on Thursday, 
January 31. Dr. Robert Looney will preside at 
the scientific sessions on Friday, February 1, The 
scientific program has been approved for sixteen 


prescribed hours of credit by the American Acad- 
emy of Family Physicians, These hours can be 
applied to the total of 150 hours of postgraduate 
study needed every three years for continued 
membership in the Academy, 

On Thursday, January 31, 1974, the Academy 
will hold its annual installation ceremonies. Of- 
ficers will be installed by James G. Price, MD, 
President of the American Academy of Family 
Physicians, 

THE NEW ORLEANS GRADUATE 
MEDICAL ASSEMBLY 

The New Orleans Graduate Medical Assembly 
has announced that scientific exhibits will be dis- 
played at their 1974 meeting March 11-14 at the 
Fairmont Roosevelt Hotel. If you have an exhibit 
you believe would be of value to the physicians 
attending the 1974 Assembly, application forms, 
rules and regulations are now available. Write to 
Dr. Rafael C, Sanchez, Chairman, Scientific Ex- 
hibits Committee, The New Orleans Graduate 
Medical Assembly, 1430 Tulane Avenue, New 
Orleans, La. 70112, for further information. 


COURSE IN LARYNGOLOGY AND 
BRONCHOESOPHAGOLOGY 

The Department of Otolaryngology, Abraham 
Lincoln School of Medicine of the University of 
Illinois and the Eye and Ear Infirmary of the 
University of Illinois Hospital, will conduct a 
continuing education course in Laryngology and 
Bronchoesophagology March 18 to 23, 1974. The 
course is limited to twenty physicians and will 
be under the direction of Paul H. Holinger, MD. 
It will be held largely at the Eye and Ear In- 
firmary, 1855 West Taylor Street, Chicago, and 
will include visits to a number of other Chicago 
hospitals. Instruction will be provided by means 
of animal demonstrations and practice in bron- 
choscopy and esophagoscopy, diagnostic and sur- 
gical clinics, as well as didactic lectures. 

Interested physicians will please write directly 
to the Department of Otolaryngology, Eye and 
Ear Infirmary, 1855 West Taylor Street, Chi- 
cago, Illinois 60612. 


34 


J. Louisiana State M. Soc. 





e View 6 


The Joys and Sorroivs of Parenthood', by Group 
for the Advancement of Psychiatry, Publica- 
tions Office, 419 Park Avenue, S, New York 
City. Charles Scribner’s Sons, New York, 
159 p, 1973, $5.95. 

This gem of .a book should find its place on 
every physician’s bookshelf. Written in a de- 
lightful style with beautiful prose and a mini- 
mum of psychiatric jargon, all physicians can 
benefit from reading it and many will find 
themselves prescribing it for their patients who 
are experiencing the joys and sorrows of parent- 
hood. It is easily read but interspersed with a 
wealth of pragmatic knowledge. Acknowledging 
the volume of writings about development, needs, 
and care of children, it attempts to fill the 
hiatus regarding the dearth of writing about the 
thought processes of parents and about what it 
is to be a parent. It articulates parenthood as 
a creative experience in self growth and not as 
an onerous guilt-laden responsibility; the needs 
of the child, of the parent, and of the mate should 
mutually reinforce one another. As a child need 
grow to adulthood, an individual cannot forever 
remain a parent. 

There is an excellent passage on the widen- 
ing of the generation gap and a warning that 
the parents, who look only to their own experi- 
ences for guidance and understanding regard- 
ing their children, are bound to encounter frus- 
tration, bewilderment, and disappointment. The 
authors remind us that moral values are also 
transmitted from children to parents. 

This book has many warning signs, but there 
is an abundance of reassurance regarding the 
flexibility and durability of the child and of the 
parent. 

The Joys and Sorrows of Parenthood points 
out the fallacy of having parents .assume that 
all their resources must be expended on their 
children, and that they are to blame for any- 
thing and everything that goes wrong with the 
child. Certainly, parents are the most major in- 
fluence on their children, but social institutions, 
relatives, and neighbors .also play crucial roles. 

Parenthood is viewed as a stage in the total 
life span which provides an opportunity for 
growth, preparing one for the next stage of the 
life cycle. While urging parents to maintain 
their autonomy, it also reminds them to re- 
examine their own values, and employ reason- 
able flexibility. Grandparenthood also is dis- 
cussed and the book concludes with a percep- 
tive, but supportive, section regarding being a 
grandparent. 

The Group for the Advancement of Psychia- 
trists is an organization of approximately 300 


psychiatrists from throughout North America 
who direct their efforts toward the study of 
various aspects of psychiatry and the applica- 
tion of this knowledge to the fields of mental 
health and human relations. They work closely 
with other specialists, including those in .allied 
fields. Their publications have maintained a 
high standard, and this present publication cer- 
tainly rates as one of their finest. 

Gene Usdin, MD 


Sleep Research and Clinical Practice] by Gene 
Usdin, Ed. Brunner/Mazel, Inc., New York 
and Butterworths, London, 94 p, 1973, $6. 
This slim volume, developed out of a sym- 
posium of the American College of Psychiatrists 
in 1972, is one of the latest in a fine series of 
publications by the college. Like the previous 
publications, this will find a good audience. As 
Gene Usdin points out in his able introduction 
to the book, this volume is mainly an appetizer 
and is not one griving “ready-made answers about 
the causes, effects, and significance of sleep.” 
It is, however, a useful and provocative primer 
to a subject that is increasing in scope and sig- 
nificance. Again Dr. Usdin puts it well in one 
of the summary introductory paragraphs when 
he states, “Studies of the relationship of phy- 
siological sleep to psychological states offer one 
of the finest opportunities for the understand- 
ing of the age old mind-body continuum.” 

The first chapter by William C. Dement and 
Merrill Mitler is a review of neurophysiological 
and neurochemical ideas on sleep. I found this 
chapter difficult as it is quite technical; but it 
is one which contains an important review of 
basic research, new experimental ideas and offers 
theoretical discussions of other areas closely 
related to sleep, besides sleep itself. 

The second chapter, by Robert L. Williams 
and Ismet Karacan, “Clinical Disorders of Sleep,” 
is a quite interesting, well organized discussion 
of sleep disorders under four major headings: 
Primary Sleep Disorders, Secondary Sleep Dis- 
orders, Parasomnias, and Sleep-Exacerbated Dis- 
orders. The .authors of this chapter make their 
point that “the study of sleep has a place in 
modern medicine,” and that, “if the treatment 
of many disorders is not based on the sleeping 
as well as the waking behavior of the patient, 
then it is only partial treatment.” In the study 
of the sleep-exacerbated disorders, there are use- 
ful clinical facts concerning heart chest disease, 
various metabolic disorders, ulcers, which I, for 
one, did not have as clear an idea, before read- 
ing this book of the sleep-related exacerbations 
common in these illnesses, as I now have. The 


JANUARY, 1974 — VOL. 126, No. 1 


35 


BOOK REVIEWS 


chapter on parasomnias is quite interesting and 
the material here, in the next chapter, and in 
the third part of the book, give some refutation 
to commonly held ideas about enuresis, sleep- 
walking, etc. These actually occur in deeper 
sleep levels and are not solely related to dreams 
which refutes the popular notion that sleep- 
walking is dream-related. There is much more 
material in the chapter on clinical disorders of 
sleep but I am only mentioning some high 
points. 

The third chapter, “Recent Advances in the 
Diagnosis and Treatment of Sleep Disorders,” 
by Anthony and Joyce Kales, contains some im- 
mediately useful information as well as further 
material along the theoretical line. They dis- 
cuss, quite interestingly, the relation of enuresis 
and sleepwalking, which was mentioned in the 
previous chapter, and carry further discussions 
of some other conditions such as nocturnal pain 
in duodenal ulcer patients, asthma, etc. Their 
discussions of insomnia and the various drugs 
used were of strong interest to me, making me 
feel (for once at least) a step ahead of the 
pharmaceutical representatives, on whom many 
of us, without the kind of information here, tend 
to rely. I will not, of course, mention which 
drugs they favor but there were some at least 
mild surprises to me. 

In summing up the volume, I find my curiosity 
whetted to read more. This is by no means a 
replacement for some of the popular works that 


have appeared on sleep and could not be con- 
sidered a definitive answer to many problems. 
It rather raises questions, points directions, and, 
if you read this worthwhile little volume, you 
will at least have a place to look for answers 
along with a beginning basis on which to or- 
ganize your thinking. This is a book for all 
physicians, non-psychiatrists and psychiatrists. 

William R. Sorum, MD 


PUBLICATIONS RECEIVED 

(Certain ones of these will be selected for review) 
American Medical Association, Chicago: Hu- 
man Sexuality, prepared by American Medical 
Association Committee on Human Sexuality. 

Appleton-Century-Crofts, New York: Medical 
Student: Doctor in the Making, by James A. 
Knight, MD. 

Doubleday & Co., New York: Medicare and 
Social Security, by Bruce Biossat; Hormones: 
Chemical Communicators, by Roger Lewin; The 
Persecuted Drug: The Story of DMSO, by Pat 
McGrady, Sr. 

Lange Medical Publications, Los Altos, Calif. : 
Current Surgical Diagnosis & Treatment, edited 
by J. Englebert Dunphy, MD and Lawrence W. 
Way, MD. 

C. V. Mosby Co., St. Louis: The Diabetic Foot, 
edited by Marvin E. Levin, MD and Lawrence W. 
O’Neal, MD ; Questions and Answers on Contact 
Lens Practice, by Jack Hartstein, MD (2nd ed.). 


36 


J. Louisiana State M. Soc. 


The Journal 


of the 


Louisiana State Medical Society 


In the United States today, 50 percent of the people die of disease 
of the cardiovascular system. This astounding figure dwarfs the next 
leading cause of death — cancer — which accounts for approximately 17 
percent of the deaths. It is true that most of the cardiovascular deaths 
occur in persons over 65 years; but cardiovascular disease accounts for 
50 percent of people dying in the age group 55 to 64 years, 42 percent 
of the deaths in the 45 to 54 year group, and 29 percent of those aged 
35 to 44 years.* With recent advances in therapy, rheumatic heart dis- 
ease, syphilitic cardiovascular disease, and hypertensive heart disease 
are receding in importance as causes of death. However, arteriosclerosis 
is picking up the slack. Of the 54 percent in the United States who died 
cardiovascular deaths, 84 percent were due to strokes and heart attacks. 

Much of the therapeutic attention today is focused on dramatic sur- 
gical interventions, late in the course of the disease, which may alleviate 
symptoms and in some cases will prolong life. However, these pro- 
cedures are palliative at best and will never significantly affect the death 
rate from cardiovascular disease. If we are to reduce this horrendous 
death rate, we must apply the methodology of the public health physi- 
cian. We must seek out the causes, educate the public and motivate 
them to avoid exposure. This issue is a special one presented by the 
Louisiana Heart Association which is devoted to risk factor reduction. 


S6.00 Pei Annum, $1.00 Per Copy 
Vol. 126, No. 2 


FEBRUARY, 1974 


Published Monthly 

1700 Josephine Street, New Orleans, La. 70113 


Jn 



David W. Wall, MD 

President, Louisiana Heart Association 


* Leading causes of death, United States 1969. 


February, 1974 — Vol. 126, No. 2 


37 



BRENTWOOD HOSPITAL 

MIDSOUTH’S COMPREHENSIVE PSYCHIATRIC HOSPITAL CENTER 

Offers the Newest Concepts in Care for Neuro-Psychiatric Disorders: 
DRUG ABUSE, NEUROLOGICAL, ETC. 


A fully carpeted hospital: featuring private and semiprivate rooms in colorful 
decor; adjacent baths, color television and individual phones available; comfortable 
day rooms. 

DIAGNOSTIC FACILITIES: 

Medical Laboratory • Radiology • Electroencephalography • Electrocardiography 

Complete Psychological Testing 

THERAPEUTIC FACILITIES: 

Social Service • Occupational Therapy • Recreational Therapy 
Educational Therapy • Psychotherapy • Electroshock Therapy 

ACCREDITATIONS: 

Fully accredited by the Joint Commission on Accreditation of Hospitals 
Affiliated with Northwestern State University School of Nursing 
American Hospital Association • Louisiana Hospital Association 
Medicare • Blue Cross 
and other Medical Insurance Programs 

Brentwood also has an Anesthesia Department and an extensively equipped Phar- 
macy, as well as a modern Dietary Department, managed by a registered dietitian. 


BRENTWOOD HOSPITAL 

1800 IRVING PLACE 

Shreveport, Louisiana 71 101 Phone (3 1 8) 424-658 1 


38 


J. Louisiana State M. Soc. 


Coronary Heart Disease in Louisiana 


• "In Louisiana, even more than in the nation as a whole, coronary 
heart disease is the most important single cause of death. It is also 
the most important cause of disability in the most productive years 
of life." 


MARGARET C. OALMANN, Dr. P.H. 

New Orleans 


^ORONARY heart disease has been the 
^ subject of much discussion, by the 
general population as well as the medical 
profession, for many years. The symp- 
toms of angina pectoris were first graph- 
ically described by Heberden in 1768. 
Edward Jenner suggested the probable 
association of coronary artery disease and 
angina pectoris in 1776. Nearly 90 years 
ago. Sir William Osier described in dra- 
matic, lyrical language the problem as he 
saw it: 

In the worry and strain of modem life, arterial 
degeneration is not only very common but devel- 
ops often at a relatively early age . . . Angio- 
sclerosis, creeping slowly but surely “with no 
pace perceived,” is the Nemesis through which 
Nature exacts retributive justice for the trans- 
gression of her laws. Nowhere do we see such an 
element of tragic sadness as in many of these 
cases. A man who has . . . strived for success . . . 
25 or 30 years with incessant toil . . . uncon- 
scious that the fell sergeant has already issued 
the warrant.! 

Even with this long history, coronary 
heart disease remains a complex, incom- 
pletely understood disease process. The 
magnitude of this problem today is re- 
vealed by the fact that coronary heart dis- 
ease is, and for a number of years has 
been, the leading single cause of death in 
the United States. Well over a million 
heart attacks occur annually in the United 
States, and over 600,000 coronary heart 
disease deaths per year are recorded; 165,- 
000 of them are in persons under 65 years 
of age.2 No country that publishes its vital 
statistics has a higher recorded death rate 

From the Department of Preventive Medicine 
and Pathology, Louisiana State University Medi- 
cal Center, 1542 Tulane Avenue, New Orleans, 
Louisiana 70112. 

February, 1974 — Vol. 126, No. 2 


for cardiovascular disease than the United 
States.^ 

Death Rates in Louisiana 
and the United States 

How does Louisiana compare with the 
rest of the nation in relation to deaths 
from coronary heart disease? If only crude 
death rates for the United States and Lou- 
isiana were considered, it would seem that 
coronary heart disease is less of a problem 
in mortality in Louisiana. However, if you 
consider, as shown in Table 1, that the age 
distribution of the United States differs 
from that of Louisiana, it is evident that 
crude death rates cannot be used for com- 
parison. A larger percentage of the Lou- 
isiana population is below 20 years of age, 
and a smaller portion of the population is 
45 years and over than in the United 
States population.^ 

TABLE I 

PERCENTAGE OF POPULATION IN EACH OF FIVE 
AGE CATEGORIES FOR THE UNITED STATES 
AND LOUISIANA AVERAGE ESTIMATED 


POPULATIONS, 1966 THRU 1969 


Broad Age 
Groups 

United States 

Louisiana 

Under 5 years 

9.7 

11.1 

5-19 years 

29.6 

32.6 

20-44 years 

30.9 

30.7 

45-64 years 

20.3 

18.0 

65 years and over 

9.5 

7.6 


The average crude death rate for all 
causes of death for Louisiana for the years 
1966 through 1969 was 900.7 per 100,000 
population, and for the United States it 
was 950.9. The average crude death rates 
for coronary heart disease (US vital sta- 
tistics code 420 for 1966 and 1967, and 
codes 410-413 for 1968 and 1969) were 

39 


CHD IN LA.— OALMANN 


246.3 for Louisiana and 291.2 for the 
United States (Table 2). 

TABLE 2 

CRUDE DEATH RATES AND AGE SPECIFIC DEATH 
RATES PER 100,000 POPULATION FOR THE UNITED 
STATES AND FOR LOUISIANA FOR ALL DEATHS 
AND FOR DEATHS FROM CORONARY HEART 
DISEASE. AVERAGED FOR 1966-1969 

Coronary 

Broad Age All Causes Heart Disease 


Groups 

US 

La. 

US 

La. 

Crude 

death rate .. 

950.9 

900.7 

291.2 

246.3 

Under 5 years 

490.8 

590.5 

0.7 

0.0 

5-19 years .... 

61.2 

73.3 

0.1 

0.2 

20-44 years .... 

212.6 

262.1 

23.7 

29.4 

45-64 years .... 

1159.2 

1354.2 

366.4 

420.1 

65 years 

and over .... 

6145.0 

6324.0 

2237.3 

2238.1 


Age specific death rates, however, were 
then calculated for this same period, 1966 
through 1969. The comparison of the Lou- 
isiana rates with the rates for the United 
States indicates that the Louisiana resi- 
dent at almost every age is at greater risk 
of dying from coronary heart disease than 
other United States residents of the same 
age. This is particularly true for the mid- 
dle-aged Louisiana resident, those 45 to 64 
years. The death rate for coronary heart 
disease in this group was 420.1 for Louisi- 
ana while the United States rate was 366.4 
per 100,000. The age specific death rates 
for deaths from all causes were also higher 
for the Louisiana residents in every age 
group. 

Previous studies of the geographic dis- 
tribution of coronary heart disease have 
disclosed the severity of the problem of 
coronary heart disease in the 45 to 64 year- 
old white men of Louisiana. Enterline pub- 
lished death rates for coronary heart dis- 
ease in white men 45 to 64 years of age 
for the 163 metropolitan and 116 non- 
metropolitan areas of the United States 
for the years 1949-51.^ All nonmetropol- 
itan areas of south Louisiana along the 
Mississippi state border and along the 
Mississippi River had coronary heart dis- 
ease death rates in the highest quartile for 
the United States. The corresponding 


areas for north Louisiana had death rates 
for coronary heart disease in the second 
highest quartile. The death rates for all 
causes in these areas — both north and 
south — were in the highest death rate 
quartiles. 

Among the 163 metropolitan areas of 
the United States, the New Orleans death 
rates ranked fifth highest for coronary 
heart disease and fourth for deaths from 
all causes. Baton Rouge ranked eighth 
and Shreveport ranked fifty-second for 
deaths from coronary heart disease. 

Death rates were calculated for all 
whites, age 45 to 74 years, for the same 
116 nonmetropolitan areas and 163 metro- 
politan areas for 1949-1951 by Sauer.® 
Among these 279 areas, New Orleans had 
the third highest death rate for coronary 
heart disease. 

Rates for coronary heart disease and for 
all cardiovascular diseases have been pre- 
sented by states in several publications.^- 
Louisiana has consistently been in the 
highest quartile of death rates. 

Discussion 

Coronary heart disease is the most fre- 
quent single cause of death in the United 
States today. The rate in this country is 
among the highest in the world. The rate 
in Louisiana is even higher than that of 
the rest of the nation. At first we might 
tend to attribute this high rate to a differ- 
ent criterion for coronary heart disease 
which would cause a larger portion of 
deaths to be assigned to this category. The 
fact that death rates for all causes are 
higher in Louisiana makes us feel that the 
high coronary heart disease death rate in 
Louisiana is real. 

We must now begin to ask what factors 
are responsible for the higher rates of 
coronary heart disease in Louisiana. Pure- 
ly endogenous, inherited factors almost 
certainly could not account for this differ- 
ence. Do our social and environmental 
factors differ so greatly from the rest of 
the nation? Consideration must be given 
to patterns of diet, occupation, physical 


40 


J. Louisiana State M. Soc. 


CHD IN LA.— OALMANN 


activity, personality, cigarette smoking 
habits and other factors. 

We must also begin thinking of the pri- 
mary prevention programs and other med- 
ical programs in the state for the preven- 
tion and control of coronary heart disease. 
With our present state of knowledge, there 
are no miracle drugs to cure coronary 
heart disease once it is diagnosed. Even 
worse, only about half of the people ex- 
periencing their first attack will live long 
enough to receive the benefits of medical 
care which are available. 

With a disease problem such as coro- 
nary heart disease, which accounts for 
about one-third of the deaths and much 
disability among the middle-aged as well 
as the older population of Louisiana, steps 
for control seem essential. 

Summary 

Coronary heart disease death rates in 
Louisiana have ranked among the highest 
in the nation for many years. These high 
rates are found in both metropolitan and 
nonmetropolitan areas. They are present 
when white males only are considered, but 
the rates are also higher than other areas 
when females and nonwhite populations 
are included. 

The parallel between death rates for cor- 
onary heart disease and death rates for all 
causes suggests that these high rates are 
probably not the result of different diag- 
nostic criteria. Some factor in our way of 
life must be contributing to the develop- 
ment of coronary heart disease. 

In Louisiana, even more than in the na- 
tion as a whole, coronary heart disease is 
the most important single cause of death. 
It is also the most important cause of dis- 
ability in the most productive years of life. 
Coronary heart disease is, therefore, not 
only a scourge to our health, but a tremen- 
dous economic burden as well. 

References 

1. Branwood AW : Modern Concepts of the Pathogene- 
sis of Coronary Atherosclerosis. E and S Livingstone, 
Ltd, London, 1963 

2. Stamler J: The primary prevention of coronary 
heart disease. Hosp Pract 6 :49-61, 1971 

February, 1974 — Vol. 126, No. 2 


3. American Heart Association: Cardiovascular dis- 
eases in the US — facts and figures. Am Heart Assoc, 
New York, pp 20-21, 1965 

4. US National Office of Vital Statistics : Vital statis- 
tics of the United States, 1966, 1967, 1968 and 1969. 
Washington, D.C., US Government Printing Office, 1968, 
1969, 1971 and 1973, vol 2, part A and B 

5. Enterline PE, Rikli AE, Sauer HI, et al : Death rates 
for coronary heart disease in metropolitan and other areas. 
Public Health Rep 75:759-766, 1960 

6. Sauer HI: Epidemiology of cardiovascular mortal- 
ity — geographic and ethnic. Am J Public Health 52:94- 
105, 1962 

7. Enterline PE, Stewart WH: Geographic patterns 
in deaths from coronary heart disease. Public Health 
Rep 71:849-855, 1956 

8. Sauer HI, Enterline PE : Are geographic variations 
in death rates for the cardiovascular diseases real ? 
J Chronic Dis 10:513-524, 1959 




ANNOUNCEMENT 


A Residency in Physical Medicine and 
Rehabilitation at Charity Hospital in New 
Orleans, La., has recently been approved 
by the Council on Graduate Education of 
the American Medical Association. 

This is a Three-Year Program 

Substitutions Allowed: 

1. 1st year substitutes for an intern- 
ship. 

2. 1 year formal credit for four years 
or more of General Practice. 

3. 1 year formal credit for residency 
training in another specialty. 


If Interested, Please Contact 

DOCTOR LARRY McKINSTRY 

Room 320, LM Building 
Charity Hospital 
1532 Tulane Avenue 

New Orleans, Louisiana Telephone: 527-8431 


41 



Louisiana State Medical Society 
Professional Liability 
Insurance Program 

It's Your Program 

By participating in the LSMS professional liability insurance program, 
you are doing more than simply buying high quality insurance at a fair 
price. You are participating in a physician managed effort to control 
present and future professional liability problems. 

Officially Endorsed 

The Hartford professional liability insurance program is the only pro- 
fessional liability insurance plan officially endorsed and sponsored by 
the LSMS. 

Administered hy 

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Coronary Heart Disease Detection Programs 

• "Since CHD is the major health problem in Louisiana, prevention 
through detection of individuals at risk seems to be the best ap- 
proach toward the control of this disease." 


^ORONARY heart disease (CHD) is 
^ well recognized as the main cause of 
death in the United States and is even 
a more serious problem in Louisiana 
than in the nation as a whole. ^ The 
great majority of deaths due to CHD 
occur outside of the hospital ; this ex- 
plains the failure of the death rate to 
decline, despite the achievements of 
coronary care units. These facts strongly 
indicate that major progi'ess in control- 
ling the CHD epidemic is possible only 
by adequate prevention. 

At a time of national preoccupation 
with the energy crisis and cost-effective- 
ness accountability, it is logical to ques- 
tion what programs will be the most 
effective and less costly in preventing 
CHD, acknowledged to be the number 
one cause of disability in the labor force 
in this country at an annual cost in the 
billions of dollars. The spectrum of sug- 
gested approaches to control this dis- 
ease is wide and controversial. At one 
extreme are those proposing preventive 
measures for the whole US population 
at once, while at the other end of the 
spectrum are those who propose the 
“do-nothing-at-this-time-approach’' since 
there is no proof of effectiveness of any 
prevention measures. Other suggested 
approaches in between the two extremes 
are those aimed either to all US adult 
men (where the incidence of the disease 
is higher) or to those adult men at high 
risk, or to screen the relatives of patients 


Dr. Alfredo Lopez-S is an associate professor 
of medicine, LSU School of Medicine, New 
Orleans. 

Work in this paper was supported by the 
National Heart and Lung Institute of U.S.P.H.S. 
Grant HL 13205-03. 

February, 1974 — Vol. 126, No. 2 


ALFREDO LOPEZ-S, MD, PhD 
New Orleans 

with the disease, or just to concentrate 
on patients who already have signs of 
the disease. 

With the present state of knowledge, 
it is safe to suggest that either extreme 
is unjustified, and that the most sensible 
approach will be the one aimed toward 
the detection of those individuals at 
higher risk regardless of age or sex. 
For this purpose, it is necessary to screen 
for susceptibles at all ages and sexes 
with the use of the most efficient and 
practical methods available in order to 
detect in the population the individuals 
with the so-called “risk factors.” 

Risk Factors 

Risk factors are those personal attri- 
butes associated with a sizable increase 
in susceptibility to suffer from prema- 
ture CHD manifestations. 

From follow-up studies^-^ of persons 
judged to be free of CHD at entry ex- 
aminations and who developed the dis- 
ease while under obseiwation, several of 
these risk factors have been identified. 
The ones most consistently identified 
and associated with excess risk are : ele- 
vated serum cholesterol levels, elevated 
blood pressure, cigarette smoking, age, 
overweight, certain electrocardiographic 
changes, a diet high in saturated fat- 
cholesterol-calories, hyperglycemia, hy- 
peruricemia, lack of physical activity, 
tachycardia, family history of CHD, and 
certain behavioral patterns. Four of the 
above factors, hypercholesterolemia, hy- 
pertension, smoking and a diet high in 
saturated fat-cholesterol-calories, are 
considered major risk factors, because 
of the extent and consistency of their 
participation in CHD and because 

43 


CHD DETECTION PROGRAMS— LOPEZ-S 


any and each of them plays an inde- 
pendent role even in the absence of any 
contributing risk factor. The effect of 
several risk factors in the same individ- 
ual is additive; individuals with one of 
the major risk factors present as com- 
pared with none have a two-fold in- 
crease in morbidity and mortality from 
CHD, while the presence of two or three 
of the risk factors attains levels of four 
or five times greater than for a group of 
individuals with none of the major risk 
factors.® 

Coronary screening as the first step 
for prevention should be aimed at de- 
tecting individuals at higher risk be- 
cause of the presence of several of the 
major risk factors. Although there is 
no conclusive proof that correction of 
such risk factors prevents or delays the 
development of overt CHD, the inferen- 
tial evidence is of such magnitude that 
makes it compulsory to modify those 
“risk factors” once they are detected in 
individual patients. 

Screening Programs 

Since CHD is a disease high in its fre- 
quency, severe in its consequence and 
with available means to detect individ- 
uals at risk, the goal of any CHD screen- 
ing program should be the early detec- 
tion of individuals at risk and the ini- 
tiation of a meaningful follow-up inter- 
vention program for those detected in- 


dividuals. The following three steps are 
essential to achieve such goals: Identifi- 
cation of high risk individuals, confirma- 
tion and follow-up. 

1. Identification: 

Given the magnitude of the problem, 
it would not be out of line to check for 
CHD risk factors in everyone between 
the ages of 25 and 59 years. Although 
this will be the ideal approach, it is prac- 
tically impossible to do so. A more prac- 
tical compromise are sporadic screening 
programs on selected groups of the pop- 
ulation (See Table 1). These programs 
are useful because they will detect un- 
suspected high risk individuals and will 
create awareness in the medical commu- 
nity and in the population as a whole 
about the CHD problem. 

Many physicians reserve CHD screen- 
ing for patients 40 years of age or older 
and do not look for risk factors in indi- 
viduals of 20 years of age. However, 
a great number of young persons are 
unsuspected carriers of CHD risk factors. 
In our yearly CHD screening program 
at the LSU School of Medicine in New 
Orleans (Fig 1, Table II) we have found 
that several of the risk factors (hy- 
perlipidemia, obesity, and hypertension) 
are present in this group of young med- 
ical students of average age 22 years. 
Obviously, if CHD preventive measures 
are to be successful, the earlier the indi- 


TABLE I 

CHD SCREENING IN DIFFERENT POPULATION GROUPS 


Population 

Advantages 

Disadvantages 

Newborn (cord blood) 

Early diagnosis 

Further reevaluation needed 

Only familial 

Type II hyperlipoproteinemias 

Grammar and high schools 

Early diagnosis 

Early corrective measures 

Captive population 

Family cooperation 
Difficult follow-up 

Young and middle-aged adults 

Higher yield 
Easier follow-up 

More difficult to organize 
if not done in doctor’s office 

Industries 

Captive population, excellent 
cooperation, facilities available 

Follow-up difficult 

Selected groups 

a) Affected 

b) Relative of affected 

Easier follow-up 

Good cooperation. Excellent yield 

Lateness 


44 


J. Louisiana State M. Soc. 


CHD DETECTION PROGRAMS— LOPEZ-S 


viduals at high risk are detected, the 
easier it will be to modify and control 
the risk factors. A more selective ap- 
proach is to encourage and to make 
screening available to all patients with 
obesity, diabetes, hyperuricemia or vas- 
cular diseases and to those with a fam- 
ily history of hyperlipidemia or prema- 
ture vascular disease. Diagnostic studies 
will be particularly relevant in relatives 
of affected patients with MI due to the 
high incidence of some of the major risk 
factors in these individuals. 


TABLE II 

AVERAGE VALUES LSU MEDICAL STUDENTS 


A^e 

Height 

Weight 

22.3 ± 1.5 years 
70.7 -+■ 2.3 inches 
. 169.5 + 23.4 lbs. 

Syst. B.P 

130 ■+■ 13 mm Hg. 

Diast. B.P 

83 -t- 9 mm Hg. 

Physical Activity 

Index (WMR/BMR) . 

. 1.7585 ± 0.1576 

Serum Cholesterol 

216 44 mg/100 ml 

Serum Triglycerides 

137 + 58 mg/100 ml 

^ — Lip oprotein 

Cholesterol 

147 -+- 38 mg/100 ml 

^ — Lipoprotein 

253 ± 63 mg/100 ml 

Pre-^ — Lipoprotein 

119 ■+■ 53 mg/100 ml 


* Mean ± standard deviations. 


Methods of Identification of High Risk 

Individuals: 

Medical History: A brief personal 
medical history including information 
about signs, symptoms, diagnosis and 
therapy of CHD, hypertension, kidney 
disease, diabetes, as well as information 
about smoking habits and physical exer- 
cise is important. Family history for 
heart attacks, hypertension, CVA and 
diabetes should also be obtained. 

Physical examination : This should 
include age, sex, height, weight, and if 
possible skinfold thickness. Presence of 
xanthomas, xanthelasma and arcus se- 
nilis should be recorded. Blood pressure 
and electrocardiograms should also be 
obtained. 

February, 1974 — Vol. 126, No. 2 


Laboratory procedures: Although 
ideally cholesterol and triglycerides de- 
terminations will detect 90 to 95 per- 
cent of subjects with lipid abnormalities, 
the determination of serum triglycerides, 
which requires fasting samples, has been 
impractical in the majority of the cases. 
This does not mean that, if possible, 
serum triglycerides should not be ob- 
tained. Evidence is at hand suggesting 
that triglycerides are also a risk factor 
for CHD independent of cholesterol.'^'® 
The same restriction of requiring fast- 
ing samples applies to lipoprotein pheno- 
typing which is a very useful technique 
and is more suitable for follow-up and 
treatment of already detected high risk 
individuals. It appears that no lipid 
parameter or battery of lipids is more 
useful for screening purposes than an 
accurate total serum cholesterol value 
in men or young women, ^ since most 
patients with hypertriglyceridemia also 
have hypercholesterolemia, and the fast- 
ing or non-fasting status of the patients 
has very little influence on the value of 
serum cholesterol. 

A great deal of confusion exists in 
the medical profession about what are 
normal serum lipid values. Average 
values found in middle-aged healthy 
American men are presented in Table 
HI. Since the average death rate for 
CHD is one of the highest in the world, 
the conclusion has to be drawn that most 
probably the “average” serum choles- 
terol in the US population is above 
what should be considered “normal” or 
“ideal.” In view of the fact that serum 
cholesterol increases with age and the 
risk for CHD increases with increasing 
values of serum cholesterol, we have 
come to the conclusion and recommend 
considering as “ideal” values of serum 
cholesterol those below 200 mg/100 ml; 
values between 200 to 250 mg/100 are 
considered in the context of o^'her risk 
factors such as age, family history of 
heart disease, etc; and values above 
250 mg/100 ml in middle-aged US indi- 

45 


CHD DETECTION PROGRAMS— LOPEZ-S 


viduals are considered high, and the in- 
dividual should be investigated further. 
This agrees with the findings in the 
Framingham study where it was found 
that the average cholesterol level of all 
men who remained free of CHD was 
200 mg/100 ml, while the average value 
for those who developed CHD was 260 
mg/100 ml. 

TABLE III 

SERUM LIPID VALUES 
AVERAGE MIDDLE-AGED U.S. MEN 


mg/ 1 00 ml 

Total cholesterol 230 ± 35 

Phospholipids 220 ± ? 

Triglycerides 105 ± 25 

Free fatty acids 3 ± ? 


Although the association between dia- 
betes and coronary heart disease has 
been well documented,^” there is no con- 
clusive evidence regarding the value, if 
any, of fasting blood sugars in the CHD 
screening laboratory work. The Ameri- 
can Heart Association has recommended 
the determination of casual (non-fast- 
ing) whole blood glucose, with a refer- 
ral cut-off of 260 mg/ 100 ml. 

An important component of any 
screening program is to make both the 
target population and the general pub- 
lic aware of the coronary risk factors 
and premonitory signs and symptoms 
of CHD so that individuals will be 
prompted to make themselves available 
for screening, rather than having physi- 
cians look for them. 

2. Confirmation: 

Confirmation of individuals at risk 
and follow-up of detected high risk indi- 
viduals are the role of the practicing 
physician. Many individuals participat- 
ing in screening programs will have 
values to be considered in the “border- 
line” range and should be reevaluated 
on referral by their private physicians or 
at +^heir usual places of medical care. 

Both major risk factors, cholesterol 
and blood pressure, may show changes 


from the values obtained at the time of 
the primary screening. Psychological, 
emotional factors and human errors 
could have affected the original blood 
pressure readings and errors in method- 
ology and individual day-to-day varia- 
tion can explain differences in serum 
cholesterol values of up to 15 percent. 

3. Follow-up: 

Whether the primary screening and 
confirmation of high risk individuals have 
taken place in the office of the private 
physician or the high risk patients have 
been referred to him, the success or 
failure of the screening program lies in 
the hands of the general physician. 
There is little advantage, and much 
anxiety can be created in screening for 
high risk individuals if no follow-up 
intervention can be delivered. In an 
accompanying paper in this issue Dr. 
Luikart“ discusses this important role 
of the private physician and the ways 
and means of treating the identified 
high risk individuals. 

Lipid profile and hyperlipoprotein- 
emia phenotyping will be indicated at 
this time in order to decide on the appro- 
priate dietary and medical treatment for 
the high risk individuals. Many times 
the conditions required to obtain an 
accurate lipoprotein and lipid profile 
are overlooked. This results in uninfor- 
mative or misleading laboratory reports 
of no benefit to the patient who has to 
pay for them nor to the doctor who 
has to make decisions based on inac- 
curate information. For such a purpose, 
before the test is done, the patient 
should be on a regular diet for one week, 
abstaining from alcoholic drinks for 3 
days, completely fasting for 12 to 14 
hours and on no medication affecting 
plasma lipids for several weeks. 

Due to shortcomings found in the 
widely used Fredrickson classification 
of lipoproteinemias, the question has 
been raised if the simple determination 
of serum cholesterol and triglycerides 
can be as useful as lipoprotein pheno- 


46 


J. Louisiana State M. Soc. 


CHD DETECTION PROGRAMS— LOPEZ-S 


typing. Most likely, nine times out of 
ten, simple measurement of cholesterol 
and triglycerides will allow the physi- 
cian to plan an adequate course of 
therapy. In the majority of the cases, 
as informative as the Fredrickson clas- 
sification of hyperlipoproteinemias, is 
the more simplified concept of three 
types of hyperlipidemias : hypercho- 

lesterolemia, hypertriglyceridemia, and 
“mixed hyperlipidemia” with both cho- 
lesterol and triglycerides elevated. These 
three types of hyperlipidemias corre- 
spond to the Fredrickson types Ila, Ilb, 
and IV hyperlipoproteinemias which are 
described in the paper by Dr. Luikart 
in this issue. These three types are the 
most commonly found in adult popula- 
tions (Table IV) and in patients with 
CHD.® Goldstein, et al,^^ have recently 
shown that among the hyperlipidemic 
survivors of patients with myocardial 
infarct, elevation in triglyceride levels, 
with or without an associated elevation 
of cholesterol levels, was three times as 
common as a high cholesterol level 
alone. Carlson and Battinger® have 
shown that a combined elevation of 
both plasma cholesterol and triglyce- 
rides carried the highest risk for coro- 
nary heart disease. This combined lipid 
abnormality (mixed hyperlipidemia j has 
been shown to be the most commonly 
found lipid abnormality in patients with 
CHD.^2-^® There is evidence suggesting 
that the majority of single or combined 
hypertriglyceridemias in the general 
population is caloric induced rather 
than carbohydrate induced. They rep- 
resent the metabolic expression of a 
caloric imbalance brought about by 
modern life-style, characterized by an 
abundant caloric intake and a reduced 
energy expenditure, and they respond 
very well to a weight reduction regime. 

In view of the high incidence of 
hyperlipidemia in relatives of patients 
who survived myocardial infarction, 
screening for coronary heart disease of 
relatives of individuals found at high 

February, 1974 — Vol. 126, No. 2 


TABLE IV 

INCIDENCE OF HYPERLIPOPROTEINEMIAS 


Population 

No. 

Age 

Normal 

Ila 

Ilb 

IV 





Percent 


Teenage* 

182 


82 

10 


6 

Young Adultsf 

400 

20-35 

68 

7.2 

10 

15 

Adultsf 

783 

52 

81 

2 

.6 

16 

All Ages° 

1061 

18-62 

72 

9 

0.2 

19 

Coronary Angiography 

No. CHD§ 

30 

46 

60 

10 


30 

CHD Present§ 

70 

51 

30 

27 

1 

43 

CHD Present^ 

52 

46 

37 

21 


42 


* Noble (17); f Lopez (15); f Harlan (18); 
° Brown (19) ; § Davis, et al (20) ; ^ Salel, et al 
( 21 ). 


risk for this disease should be very 
profitable and of extreme use in the 
early detection and early prevention of 
the disease. 

Let me illustrate with two examples 
what can be accomplished through 
coronary heart disease screening pro- 
grams : 

During our annual CHD screening 
program in freshmen medical students 
at LSU,^® we found one of them to have 
elevation of both cholesterol and trigly- 
cerides. The values were confirmed in 
a subsequent study. A dietary and exer- 
cise program of weight reduction was 
prescribed. After a few weeks in this 
regime, and after losing eight pounds 
of weight, new lipid studies showed that 
this student had hypercholesterolemia 
(type Ha hyperlipoproteinemia^. Screen- 
ing of the family, including the father, 
a physician, and three brothers, showed 
that all of them had familial hypercho- 
lesterolemia. Specific treatment was ini- 
tiated in our student, and as can be seen 
in Fig 2, with adequate treatment we 
have been able to reduce serum lipids 
and body weight to more normal levels. 
We hope that with this change the risk 
of the student has been greatly reduced. 
At the same time, his family has been 
made aware of similar disease and risk 
in the other members. 

Under the auspices of the Louisiana 

47 


CHD DETECTION PROGRAMS— LOPEZ-S 


Heart Association, a Coronary Risk De- 
tection and Modification Program was 
carried out in the Ormet Plant (Bum- 
side, La.) which is the first such large 
screening program in Louisiana. Author- 
ization and cooperation from the plant 
management and physician were re- 
quested and were easily obtained as 
well as approval of the local medical 
society and endorsement by the Louisi- 
ana State Medical Society. A total of 
511 workers of average age 41 years 
was screened on four consecutive Thurs- 
days. Three hundred and fifty-one 
(68.8%) of the screenees were found 
to have one or more risk factors 
(Table V), and they were referred to 
their physicians for confirmation and 
follow-up. On the basis of their risk 
factors, their probability of suffering 
CHD in the next six years (Coronary 
Risk Index = CRI) was calculated,^® and 
it was found that the CRI was higher 
for the average Ormet employee than 
for individuals of the same age in Fram- 
ingham, Massachusetts. One of the 
screenees, found to have one of the high- 
est CRI, three times higher (12%) than 
the average CRI for individuals of his 
age (4%), has already died, victim of 
a myocardial infarct. For him detec- 
tion was too late. 

The distribution of hyperlipoprotein- 
emia abnormalities in these workers 


gives us an idea of the probable prev- 
alence of these types of lipid disorders 
in the general adult population in Louisi- 
ana (Table VI) and shows a higher in- 
cidence of types Hb and IV in this adult 
population. 

TABLE VI 

INCIDENCE OF HYPERLIPOPROTEINEMIA 
IN ORMET PLANT 
(Total — 51 I Workers) 



Number 

Per- 

centage 

Normal 

363 

72 

Type Ila 

25 

5 

Type Ilb 

19 

4 

Type IV 

104 

20 


Summary 

Since CHD is the major health prob- 
lem in Louisiana, prevention through 
detection of individuals at risk seems 
to be the best approach toward the 
control of this disease. Screening in two 
segments of the Louisiana population 
has shown an alarming presence of coro- 
nary risk factors in young medical stu- 
dents and a higher coronary risk index 
in the adult employees of an industrial 
population when compared with indi- 
viduals of the same age in other parts 
of the country. The prevalence of hyper- 
lipoproteinemias characterized by eleva- 
tion of triglycerides was higher than the 
hyperlipoproteinemias characterized by 
cholesterol elevation alone. 


TABLE V 

NUMBER OF PERSONS WITH ABNORMAL CLINICAL AND LABORATORY RISK FACTOR FINDINGS 

BY AGE GROUPS ORMET PLANT 


Total No. of 


With No 
Risk Factors 

With One 
Risk Factor 

With Two 
Risk Factors 

With Three 
Risk Factors 

With Four 
Risk Factors 

Persons With 
Risk Factors 

Tested 

Percent 

Percent 

Percent 

Percent 

Percent 

of All 

of All 

of All 

of All 

of All 

of All 

No. Tested 

No. Tested 

No. Tested 

No. Tested 

No. Tested 

No. Tested 


1-19 years 

20-29 years 

30-39 years 

40-49 years 

50-59 years 

60 years and older 
T otal 


2 

34 

100.0 

53.1 

22 

34.4 

6 

9.4 

54 

35.5 

53 

34.9 

29 

19.1 

46 

24.1 

67 

35.1 

49 

25.7 

21 

23.6 

27 

30.3 

29 

32.6 

3 

23.1 

4 

30.8 

4 

30.8 

160 

31.3 

173 

33.9 

117 

22.9 


2 

3.1 



30 

46.9 

12 

7.9 

4 

2.6 

98 

64.5 

25 

13.1 

4 

2.1 

145 

75.9 

11 

12.4 

1 

1.1 

68 

76.4 

2 

15.4 



10 

76.9 

52 

10.2 

9 

1.8 

511 

100.0 


48 


J. Louisiana State M. Soc. 


CHD DETECTION PROGRAMS— LOPEZ-S 



Serum Cholesterol mg/IOOmI 



/9-Lipoprotein Cholesterol mg/IOOmI 



Fig 1. Distribution of serum lipids in fresh- 
men medical students. 



“1 1 1 1 1 l““T 1 1 1 1 1 1 1“ 

2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 


Months 

Fig 2. Effect of dietary and medical treatment 
in a young individual with type Ila hyperlipopro- 
teinemia. 


Acknowledgement 

The technical assistance and advice 
of Dr. J. A. Hebert, Miss Lillie Bell and 
Mr. Charles S. Wingo are greatly appre- 
ciated. 

References 

1. Oalmann MC: Coronary heart disease in Louisiana. 
J La State Med Soc, vol 126, page 39, 1974 

2. Keys A. Blackburn H: Background of the patient 
with coronary heart disease. Progr Cardiovasc Dis 6 :14, 
1963 

3. Kannel WB, Dawber TR, McNamara PM: Detection 
of the coronary prone adult: The Framingham Study. 
J Iowa Med Soc 56:26, 1966 

4. Stamler J : Lectures in Preventive Cardiology. New 
York, New York, Grune and Stratton, 1967 

5. Gordon T, Kannel WB : Multiple contributors to 
coronary risk. Implications for screening and prevention. 
J Chronic Dis 26:561, 1970 

6. Report of Inter-Society Commission for Heart Dis- 
ease Resources Primary Prevention of the Atherosclerotic 
Diseases. Circulation 2, A-55, 1970 

7. Goldstein JL: Genetic aspects of hyperlipidemia in 
coronary heart disease. Hospital Practice (Oct) 53, 1973 

8. Carlson LA, Bottiger, LE: Ischaemia heart disease 
in relation to fasting values of plasma triglycerides and 
cholesterol. Lancet i, 865, 1972 

9. Kannel WB : Lipid profile and the potential coro- 
nary victim. Am J Clin Nutr 24:1074, 1971 

10. Stamler J : Epidemiology of coronary heart disease. 
Med Clin N A 57:5, 1973 

11. Luikart WM ; Coronary risk reduction in office 
practice, J La Med Soc, vol 126, page 51, 1974 

12. Goldstein JL, Hazzard WR, Schrott HG: Hyper- 
lipidemia in coronary heart disease. J Clin Invest 52:1633, 
1544, 1973 

13. Nikkila E, Aro A: Family study of serum lipids 
and lipoproteins in coronary heart disease. Lancet i, 964, 
1973 

14. Hall Y, Stamler J, Cohen DB: Effectiveness of a 
low saturated fat. low cholesterol, weight-reducing diet 
for the control of hypertriglyceridemia. Atherosclerosis 
16:389, 1972 

15. Balart L, Moore MC, Gremillion L: Interrelation- 
ships between serum lipid values, dietary intakes and 
physical exercise in young medical students. J AM Diet 
Assoc 64, 42. 1974 

16. Gordon T, Sorlic P, Kannel WB : Coronary heart 
disease; ABI, IC — A multivariate analysis of some fac- 
tors related to their incidence. Framingham Study — 
16 yr. follow-up. Section 27, US Government Printing 
Office 1971 

17. Noble RP: Abnormal lipoprotein patterns in young 
men. Circulation 27-28, Supl. VI, 18, 1968 

18. Harlan WR: Personal communication 

19. Brown DF: Hyperlipoproteinemia. Prevalence in 
1300 blood donors. Circulation 44, Supl. II, 33-34, 1958 

20. Davis R, Kong Y, Sabiston D : Hyperlipoprotein- 
emias in coronary artery disease. Clin Res 19:310, 1971 

21. Salel AF, Armsterdam EA, Mason DT: The im- 
portance of type IV hyperlipoproteinemia as a predis- 
posing factor in coronary artery disease. Clin Res 19:485, 
1971 


February, 1974 — Vol. 126, No. 2 


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Coronary Risk Reduction in Office Practice 

• ”1+ is true of course that reduction of the risk factors is no guar- 
antee of avoiding coronary events; but it appears probable that the 
risk will be correspondingly reduced . . 


A THEROSCLEROSIS and hyperten- 
sion, singly or combined, account 
for the overwhelming majority of the 
total case load of cardiovascular dis- 
ease. To this day, the most common 
clinical diagnosis of serious persistent 
disease is hypertensive and arterioscle- 
rotic heart disease. Stroke due to hyper- 
tension and atherosclerosis is not much 
less frequent a finding in the overall 
tabulation of serious disease states.^ The 
constancy of the interplay between ath- 
erosclerosis and hypertension must strike 
the medical observer as more than for- 
tuitous, and at the same time suggests 
that a fundamental relationship exists 
between the two. 

Several decades of basic research 
have yielded an immense literature but 
not absolute answers to the ever increas- 
ing morbidity and death rates from ath- 
erosclerotic coronary artery disease. 
Fascinating hints of important relation- 
ships can be perceived among several 
factors. From an etiologic standpoint, 
ovemutrition, lipid disorders, carbohy- 
drate intolerance and purine metabolic 
errors on the one hand ; and hyperten- 
sion, the renin-angiotensin-aldosterone 
mechanism and salt metabolism, on the 
other; and from a precipitating or modi- 
fying standpoint, stress and strain, ciga- 
rette smoking, inactivity, and catechola- 
mine effects — all are under scrutiny. 
As yet no clear unifying thread linking 
all the data has been delineated, al- 
though some schemes have been sug- 
gested,^ and a solution may be years 
away. But the concept of risk factors 
for propensity to premature coronary 
disease has risen from epidemiologic 
and statistical data.^*^ 

February, 1974 — Vol. 126, No. 2 


WILLIAM M. LUIKART, MD 
Baton Rouge 

The concept of risk factors appears to 
be the most reasonable model thus far 
presented in clinical attempts to control 
the ravages of atherosclerotic coronary 
artery disease. Indeed it is the only 
working model available. 

The risk factors to be considered are : 
elevated serum lipids,®-'^ hypertension,® 
carbohydrate intolerance or diabetes,® 
cigarette smoking,^® inactivity or seden- 
tary habits, ovemutrition and obesity,^^ 
and stress and strain. Factors which 
cannot be altered in the sense of pre- 
vention, but useful from a diagnostic 
standpoint are: family history and ab- 
normal electrocardiogram. 

The concept holds that these factors 
should be identified and, insofar as pos- 
sible, countered with available thera- 
peutic maneuvers of probable benefit 
and improbable harm. In this context, 
the office reduction of risk factors for 
coronary heart disease in private prac- 
tice can be considered. 

Patients may be evaluated in private 
practice, self-referred because of a feel- 
ing that there are possibilities of pre- 
ventive medicine, from a risk factor 
screening program referral,^® or as con- 
tinuation of complete care for any 
patient seen for any purpose. 

Special Aspects of Workup 

History — Family history of premature 
coronary artery disease, of diabetes, of 
gout, of hypertension; personal history 
of cigarette smoking, alcohol intake, in- 
activity, environmental stress and strain, 
hypertension and nutritional habits which 
may be in excess of need. 

Physical Examination — Blood pressure 
in each arm and in a leg, seated and 

51 


CORONARY RISK REDUCTION— LUIKART 


standing and after exercise; ocular fundi; 
cutaneous or subcutaneous xanthomata; 
bruits in the neck, over the back of the 
thorax, over the renal artery areas; pe- 
ripheral pulses; cardiac enlargement, api- 
cal thrust, murmurs and rhythm; abdomi- 
nal masses or organomegaly; peripheral 
edema. 

Special Tests — Urinalysis, serum uric 
acid, two-hour postprandial blood glucose; 
serum lipid study and classification of 
pattern according to the modified Freder- 
ickson scheme (Table 1). 


TABLE I 

USUAL PATTERNS OF LIPID DISORDERS* 



Chylo- 

LDL 

Choles- 

VLDL 

Trigly- 

Floating 

Type 

mlcra 

/3 LP 

terol 

pre P LP 

cerlde 

LP 

I 

+ 




+ 


IIA 


+ 





IIB 


+ 


-b 

+ 


III 


-f 



-b 

-b 

IV 



± 

-b 

-b 


V 

-b 



+ 

+ 



LDL = Low density lipo^^rotein. VLDL =z Very 
low density lipoprotein. LP = Lipoprotein. + = 
Increased or positive. ± = Normal or increased. 


* Uncertain diagnosis may require repeat stud- 
ies on stable diet and after 15-hour-long fasting. 
At times ultracentrifuged specimen analysis may 
be necessary. (Adapted from Frederickson) 

Consideration of Individual Factors 

Serum Lipid Disorders — Since all of 
these types except Type III may be sec- 
ondary to other disorders, a search for 
etiologies is undertaken. The possibilities 
are: 


Diabetes, myxedema, nephrosis, dys- 
proteinemia, pancreatitis, obstructive 
liver disease, dietary peculiarities, preg- 
nancy and administration of gestational 
hormones. Any one of these which may 
be present is treated or managed as 
needed, and such management may nor- 
malize the lipid pattern. It should be 
borne in mind, particularly in the case 
of diabetes, that correction of the pri- 
mary condition may fail to normalize 
the pattern since a familial hyperlipo- 
proteinemia may exist independently. 

We are concerned here with Types 
II, Ilb, and IV which are associated 
with premature atherosclerotic coronary 
artery disease (see Table 2). Types II 
and III are especially associated with 
xanthomata. Type IV patients are par- 
ticularly liable to be obese. Types II 
and IV are reported to be common and 
about equally prevalent. In our experi- 
ence, Type IV is by far the more com- 
mon. Type III is rare. 

Recommended diet and medication for 
these conditions are shown in Table 3. 

Alcohol intake must be sharply re- 
stricted in Types lib, III, and IV. Dex- 
trothyroxine is useful in Types II and 
III but is contraindicated in the presence 
of clinical coronary artery disease, an- 
gina, and any tendency to ventricular 
arrhythmia.^® It should be used with 
great caution if at all. 

Cholestyramine very effectively low- 
ers the serum cholesterol level in many 


TABLE 2 

SOME CLINICAL ASSOCIATIONS OF HYPERLIPIDEMIAS 


Type 

Xanthoma 

Coronary 

risk 

Carbohydrate 

sensitive 

Fat 

sensitive 

I 

Eruptive 

Low 

No 

Yes 

IIA 

Premature Arcus 

Palmar (Planar) 

Tuberous 

Xanthelasma 

Very high 

No 

Yes 

IIB 

Same as IIA 

Very high 

Yes 

Yes 

Ill 

Same as II 

Tuboeruntive 

Very high 

Yes 

No 

IV 

Tub 0 eruptive 

High 

Yes 

No 

V 

Eruptive 

Not very high 

Yes 

Yes 


52 


J. Louisiana State M. Soc. 


CORONARY RISK REDUCTION— LUIKART 



TABLE 3 

DIET AND DRUG TREATMENT OF HYPERLIPIDEMIASi^-is 


Type 

Therapeutic diet 

Medications of value 

I 

Low fat 

None 

IIA 

Low saturated fat 

Increased polyunsaturates 
Restrict cholesterol to 300 mg 

Cholestyramine 
Nicotinic acid 
Dextrothyroxine^® 

IIB 

Same as IIA 

and weight reduction 
Restrict carbohydrate 

Same as IIA 
and Clofibrate 

Ill 

Weight reduction 

Restrict carbohydrate 
Limit alcohol 

Substitute unsaturated fat 

Clofibrate 
Nicotinic acid 
Dextrothyroxine^® 

IV 

Same as III 

Clofibrate 
Nicotinic acid 

V 

Weight reduction 

Restrict fat 
Restrict carbohydrate 
and alcohol 

Clofibrate 
Nicotinic acid 


individuals. About 20 grams a day are 
required. It is unpleasant to take and 
may produce gastrointestinal symptoms. 

The serum triglyceride and choles- 
terol levels should be checked at three 
month intervals and the serum lipopro- 
tein pattern once or twice a year. It 
should be noted that the pattern may 
change with treatment, and manage- 
ment may need to be adjusted accord- 
ingly. 

The dietary prescription is greatly 
simplified by the use of National Heart 
and Lung Institute diet booklets (avail- 
able from the Office of Heart and 
Lung Information, National Institutes of 
Health) which are keyed to the several 
lipid disorders described here. Fre- 
quently it is useful to arrange a con- 
sultation with the patient’s spouse and a 
dietician who is conversant with this 
type of program. 

The American Heart Association’s 
handbook^’^ for dietary treatment of the 
hyperlipidemias is most satisfactory. 

We find that Type II will seldom 
respond to diet alone and prescribe drug 
therapy routinely; and since patients 
often do not follow any diet carefully, 
we usually find that drug therapy is 
required. Obviously the dietary regime 


followed even partly is better than 
drugs alone. We find that we must 
have a high index of suspicion for the 
tendency of patients to follow fad diets 
on their own. 

Hypertension — Hypertension is by far 
the most common risk factor discovered, 
and while its key role is in the incidence 
of stroke (which we are anxious to avoid 
also) it is probably important in the inci- 
dence of coronary artery disease as well. 
Our emphasis is on treating hypertension 
with drugs to reduce the blood pres- 
sure below 160 systolic and 90 diastolic, 
whether an etiology for the high blood 
pressure is discoverable or not.^® Further 
workup may be suggested by certain phys- 
ical findings such as bruits, or leg pres- 
sures lower than arm pressures, or weak- 
ness or hypokalemia resulting from po- 
tent diuretics, and these can be pursued 
as indicated; but the pressure itself is 
treated primarily.^® Weight reduction in 
the obese and moderation of salt intake 
in all are urged. The drug regime is 
initiated with a diuretic. To this is added, 
if needed, either methyldopa or rauwolfia. 
To these are added hydralazine, if neces- 
sary. Guanethidine may be necessary in 
resistant cases. Potassium supplementa- 
tion is used as needed, and the blood lev- 


February, 1974 — VOL. 126, No. 2 


53 


CORONARY RISK REDUCTION— LUIKART 


els of urea, glucose, uric acid and potas- 
sium are monitored at intervals. Stand- 
ing blood pressures are recorded in those 
taking guanethidine. Due regard is given 
to the possible occurrence of depression 
(rauwolfia) and the possible occurrence 
of drug fever (methyldopa) . 

Diabetes — Diabetes is of course man- 
aged for itself. The standard American 
Diabetes Association diets must at times 
be adapted to the specific requirements 
of a particular lipoprotein disorder. Com- 
monly Type IV is found in diabetics and 
responds to diabetic management includ- 
ing the avoidance of sucrose. When the 
diabetes is stabilized, the serum lipopro- 
tein pattern should be reevaluated, and 
management of the current lipid status 
may need to be reassessed.^^ 

Cigarette Smoking — This is discour- 
aged in a sympathetic way. To those 
who cannot quit all at once (the vast 
majority) I ask them to change brands 
to a filter, and progressively each month 
to a cigarette of lower and lower tar 
and nicotine production. I stipulate which 
brands to use according to official data 
on tar and nicotine content. I do not hesi- 
tate to prescribe sedation to facilitate the 
gradual reduction in frequency of smok- 
ing and recommend specific impediments 
to easy access to cigarettes. I ask the 
patients to record the sequence of events 
which leads to their automatic or reflex 
ignition of each cigarette and then try to 
place obstacles in the way of such se- 
quence. I do suggest a pipe as an alter- 
native if necessary. I have not found 
antismoking clinics to be of lasting value, 
but a few of my patients have succeeded 
with these. 

Exercise — Walking, bicycling and swim- 
ming are encouraged. Isometric exercises 
and superheated saunas are forbidden. 
The emphasis is on beginning at a very 
modest degree of exercise with gradual 
increments over a period of time to build 
up to a considerable program of regular 
daily activity.^^ 

Overnutrition and Obesity — These are 


specifically treated in connection with cer- 
tain hyperlipoproteinemias (see Table 2). 
As for the general status of obesity 
(weight in excess of 125% of ideal) 
the importance of its correction is de- 
bated. There is some evidence that 
obesity of itself is associated with an 
increased risk of premature death. 
Weight reduction success depends heavi- 
ly on the motivation of the patient and 
this in turn on the motivation of the 
physician. The time expended by the 
latter will sometimes be rewarded by 
patient cooperation. I frequently refer 
“caloricolic” patients to the group ther- 
apy offered by commercial organiza- 
tions, always with due surveillance for 
possible undesirable biochemical results 
of their dieting. Psychiatric consulta- 
tion, occasionally sought, has sometimes 
been helpful. 

Stress and Strain — These are known 
to alter serum lipids and hyperglycemia 
at least in the acute situation. Emo- 
tional factors certainly aggravate an- 
ginal syndrome and hypertension, and 
often coincide with the first onset of 
coronary events. Whether this is medi- 
ated by hypothalamic-pituitary-adrenal 
axis effects or coincidental is perhaps 
arguable. In any event, little can be 
done beyond application of the recog- 
nized principles of mental hygiene and 
the cautious use of sedative and anti- 
depressant drugs with keen regard for 
drug interactions, enzyme induction and 
drug habituation. As for physical stress 
and strain, the place of this as a factor 
in coronary events remains undecided 
and will not be discussed here. 

Estimating Risk of Heart Disease 

The American Heart Association has 
developed a handbook^^ for estimating 
coronary risk probability in the patient 
without clinical evidence of the disease 
based on multivariate analysis of the 
Framingham data. A copy of a sample 
page from this publication is shown in 
Table 4. The tables are arr?mged so 
that the characteristics of a given pa- 


54 


J. Louisiana State M. Soc. 


SAMPLE PAGE FROM CORONARY RISK HANDBOOK 
(40-YEAR-OLD MAN) 


CORONARY RISK REDUCTION — LUIKART 


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lb 

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180 


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165 


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E° 


February, 1974 — Vol. 126, No. 2 


55 


developing coronary heart disease in six years is 2,3 percent. 


CORONARY RISK REDUCTION— LUIKART 


tient are considered in the following 
order : 

1) Sex; 2) Age rounded to the near- 
est 5-year interval; 3) Cigarette smok- 
ing; no — yes; 4) LVH by ECG: nega- 
tive — positive; 5) Glucose intolerance: 
absent — present. 

The probability of developing coro- 
nary heart disease in a six-year period 
is obtained from the body of the 
table by: 

1) Rounding the patient’s choles- 
terol and systolic blood pressure values 
closest to those in the margins of the 
tables; and 

2) Finding the intersection of the 
patient’s cholesterol and systolic blood 
pressure in the body of the table. 

Example : Male, age 38. Smokes more 
than 20 cigarettes per day. Has normal 
resting ECG. Two-hour postprandial 
blood sugar is 210. Cholesterol is 283. 
Systolic blood pressure is 158. 

The table (shown) for a 40-year-old 
man is found. In the upper half (LVH- 
ECG negative) ; the right upper quad- 
rant (smokes cigarettes) is located. The 
lower portion of this quadrant (glucose 
intolerance present) is considered. 

The cholesterol of 283 rounds off to 
285 in the cholesterol column; the sys- 
tolic blood pressure of 158 is nearest in 
number to 165 in the SBP row. At the 
intersection of CHOL 285 and SBP 165 
the probability of 14.6 is found. 

It can then be stated that the patient 
has a 14.6 percent probability of devel- 
oping (clinically apparent) coronary 
heart disease in the next six years. 

This probability can be compared 
with the probability at average values 
for Framingham men, aged 40, of 2.3 
percent. Thus the patient may be said 
to have a risk six times greater than 
average (14.6/2.3). 

Similarly, if the same man did not 
smoke, had absent glucose intolerance, 
a cholesterol of 185 and a SBP of 105, 
his probability would be 0.7 percent or 
only 1/3 of the average risk. 


The actual data on the patient could 
of course be applied directly in the ap- 
propriate equation, using an adequate 
computer, to calculate the risk more 
precisely.^2 

This exercise serves to emphasize that 
the risk factors are quantifiable and are 
a continuum: that is, each increment in 
each factor increases the risk. 

Finally, quantifying the risk factors 
provides a clear picture of the patient’s 
problem, permits goal setting and allows 
an assessment of progress periodically. 

It is true of course that reduction of 
the risk factors is no guarantee of avoid- 
ing coronary events ; but it appears 
probable that the risk will be corre- 
spondingly reduced and after all, all of 
medicine is probabilistic as are indeed 
all of the physical sciences. 

References 

1. Arteriosclerosis, a report by the National Heart and 
Luni? Institute Task Force on Arteriosclerosis. 1, June 
1971 (DHEW Pub No (NIH) 72-137) 

2. Hollander W : Hypertension, antihypertensive drugs 
and arteriosclerosis. Circulation 48:1112-1127, 1973 

3. Keys A, Aravanis C. Blackburn H, et al: Probability 
of middle-aged men developing coronary heart disease in 
five years. Circulation 45 :815, 1972 

4. Truett J, Cornfield J, Kannel W : A multivariate 
analysis of the risk of coronary heart disease in Framing- 
ham. J Chron Dis 20:511, 1967 

5. Wilhelmsen 1>, Wedel H, Tiblin G: Multivariate 
analysis of risk factors for coronary heart disease. Circu- 
lation 48:950-958, 1973 

6. Keys A, Kimura N, Kusukawa A, et al: Lessons 
from serum cholesterol studies in Japan, Hawaii and 
Los Angeles. Ann Intern Med 48:83, 1958 

7. Kannel W, Dawber T, Friedman. G, et al: Bisk fac- 
tors in coronary heart disease : An evaluation of several 
serum lipids as predictors of coronary heart disease: The 
Framingham Study. Ann Intern Med 61:888, 1964 

8. Freis E: Hypertension and arteriosclerosis. Am J 
Med 46:735. 1969 

9. Ostrander L. Neff B, Block W, et al: Hypergly- 
cemia and hypertriglyceridemia among persons with coro- 
nary heart disease. Ann Intern Med 67 :34, 1$67 

10. Auerbach O, Hammond E, Garfinkel L: Smoking 
in relation to atherosclerosis of the coronary arteries. 
New Eng J Med 273-775, 1966 

11. Kannel W : Obesity and coronary heart disease. 
Nutrah (American Heart Association EM 607) : vol 1 
No 3 

12. Loi>ez-s A: Coronary heart disease detection pro- 
grams. J La Med Soc, vol 126, page 43, 1974 

13. Frederickson DS: A physician’s guide to hyperlipi- 
demnia. Mod Cone Cardiov Dis 41:31-36, 1972 

14. American Heart Association: Diet and coronary 
heart disease (EM 379), 1973 

15. Levy R, Fredrickson DS, Shulman R, et al: Diet- 


56 


J. Louisiana State M. Soc. 


CORONARY RISK REDUCTION— LUIKART 


ary drug treatment of primary hyi>€rlipoproteinemia. Ann 
Intern Med 77:267-294, 1972 

16. The Coronary Drug Project: Findings leading to 
further modifications of its protocol with respect to dex- 
trothyroxine. JAMA 220:996-1008, 1972 

17. American Heart Association: A Maximal Approach 
to the Dietary Treatment of the Hsrperlipidemias, a hand- 
book for physicians and four diets for patients (EM 
585 ABCD), 1973 

18. American Heart Association: Hypertension Office 
Evaluation (EM 375), 1972 

19. Finnerty F: Drugs used in the treatment of hyper- 
tension. Mod Cone Cardiov Dis 43 :33-40, 1973 


20. Freis E: Mechanism of antihypertensive effects 
of diuretics : Possible role of salt in hypertension. J Clin 
Pharmacol Ther 1:337, 1960 

21. Dahl L: Salt and hypertension. Am J din Nutr 
25:231-244, 1972 

22. Chance G, Albutt E, Edkins S: Serum lipids and 
lipoproteins in untreated diabetic children. Lancet 1:1126- 
1128, 1969 

23. American Heart Association: Exercise Testing and 
Training of Apparently Healthy Individuals : A Handbook 
for Physicians (EM 565), 1972 

24. American Heart Association: Coronary Risk Hand- 
book (EM 620), 1973 


HIBeRPlia 

nanonaL 


February, 1974 — Vol. 126, No. 2 


57 



r^cLcuoio ^i^ f CL^e 


Coronary Angiography in Chest Pain 


LACY H. WILLIAMS, MD 
MASAHIRO MORI, MD 
ROBERT T. LAFARGUE, MD 
Shreveport 


^ORONARY arteriography has proved 
^ to be a useful tool in the diagnosis 
of patients with chest pain. It gives 
excellent anatomical visualization of the 
coronary circulation. While it is com- 
monly thought of as a preoperative pro- 
cedure prior to coronary revasculariza- 
tion, it is also extremely helpful in those 
patients who have atypical chest pain 
and nonspecific electrocardiographic 
findings. It is also indicated in those 
patients who have angina in association 
with valvular heart disease prior to 
their undergoing corrective surgery. 

Case Report 

A 55-year-old white woman presented at the 
T. E. Schumpert Memorial Hospital with a his- 
tory of sustaining a “heart attack” in February 
of 1973. After an uneventful recovery, she ex- 
perienced episodes of severe, substemal pain, 
associated with a choking sensation, which radi- 
ated into the neck and left arm. The discomfort 
was precipitated by exercise, especially with 
using the arms and emotional distress, but did 
not occur after eating or at night. The patient 
gave no history of the usual coronary risk fac- 
tors, and serum lipid studies revealed no evidence 
of familial hyperlipoproteinemia. A graded 
treadmill exercise study was positive revealing 
ischemic ST depression. Therapy with propran- 
olol (Inderal) 40 mg qid and isosorbide dini- 
trate (Isordil) 5 mg sublingually qid produced 
definite improvement in the patient’s symptom- 
atology. Because of the clinical picture, a 
selective coronary arteriogram with left ventric- 
ular angiography was performed. 


From the cardiovascular laboratory, T. E. 
Schumpert Memorial Hospital. 

Dr. Williams is a radiologist. Dr. Mori and 
Dr. Lafargue are cardiologists. 


Radiographs 



Fig 1. Left coronary artery. A. Circumflex 
coronary artery. B. Left anterior descending 
coronary artery. 



Fig 2. Right coronary artery. 
What is your diagnosis? 


58 


J. Louisiana State M. Soc. 


RADIOLOGY PAGE 


Radiographic Diagnosis 

Using the transfemoral technique, as 
described by Judkins, both coronary 
arteries were catheterized and both cine 
and spot film angiograms were obtained 
in multiple projections. The films ob- 
tained reveal minimal arteriosclerotic 
change of the left anterior descending 
coronary artery, but significant obstruc- 
tion to flow was not identified. Left 
ventricular angiography was also per- 
formed, and this showed no abnormality 
of cardiac contraction. The study was, 
therefore, interpreted as showing no 
significant evidence of coronary artery 
disease. 

Discussion 

In recent years, a group of patients 
has been identified by coronary arteri- 
ography who have angina-like chest 
pain and normal coronary arteriograms. 
In almost 50 percent of these patients, 
chest pain is characteristic of angina 
pectoris. Many patients respond to pro- 
pranolol and nitrate therapy. A resting 
electrocardiogram may be normal or 
reveal nonspecific ST-T abnormalities. 
Exercise stress testing in 30 percent of 
these patients is positive revealing ST 
depression of 1 mm or more. Hyperten- 
sion and hyperlipoproteinemia have 
been observed. Many investigators find 
approximately 50 percent of these indi- 
viduals are cigarette smokers. From the 
clinical picture, it is often not possible 
to exclude obstructive coronary artery 
disease. 

The clinical course of those with nor- 
mal coronary angiograms is benign, and 
prognosis is good. During follow-up 
periods up to six years, there has been 
no incidence of proven myocardial in- 
farction, and the mortality rate is no 
higher than that of the general popula- 
tion. The case presented here stresses 
the importance of performing coronary 
arteriography as a part of the diagnostic 
evaluation. Without this procedure, 
many of these patients have been diag- 
nosed as having obstructive coronary 


artery disease and have been subjected 
to the psychologic and socioeconomic 
implications of this condition. 

Although the etiology of this syn- 
drome is not completely understood, the 
following possibilities have been ad- 
vanced : 

a. Coronary artery spasm with redis- 
tribution of blood in the coronary micro- 
circulation. 

b. ' Small vessel disease of the coro- 
nary arteries. 

c. Abnormal Hgb-02 dissociation 
(“Stingy” hemoglobin syndrome). 

d. Misinterpretation of coronary an- 
giogram. 

e. Cardiomyopathy 

f. Psychosomatic factors. 

References 

1. Herman MV, Cohn PF, Gorlin R: Editorial: An- 
gina-like chest pain without identifiable cause. Ann Int 
Med 79:445, 1973 

2. James TN: Editorial: Angina without coronary 

disease (sic). Circulation 42:189, 1970 

3. Judkins, MP: Selective coronary arteriography. A 
percutaneous transfemoral technique. Radiology 89:815- 
824, 1967 

4. Kemp Jr HG, Vokonas PS, Cohn PF, et al: The 
anginal syndrome associated with normal coronary arteri- 
ograms. Report of a six year experience. Am J Med 
54:735, 1973 

5. Waxier EB, Kimbiris D, Dreidus LS: The fate of 
women with normal coronary arteriograms and chest pain 
resembling angina pectoris. Am J Cardiol 28:25, 1971 





February, 1974 — ^Vol. 126, No. 2 


59 


Electrocardiogram 
of the Month 


Editors 

JOE W. WELLS. MD 
NORTON W. VOORHIES. MD 
ADOLPH A. FLORES. JR.. MD 
LAWRENCE P. O'MEALLIE. MD 
New Orleans 


STEPHEN P. GLASSER, MD 
Shreveport 



Your interpretation? (Leads I, II and III are recorded simultaneously). 


Elucidation is on page 61. 


Dr. Glasser is an assistant professor of medicine and chief of the Cardiology Section, LSU School 
of Medicine, Shreveport. 


60 


J. Louisiana State M. Soc. 


ELECTROCARDIOGRAM OF THE MONTH 


Electro- 
cardiogram 
of the Month 


ELUCIDATION 


This ECG was taken on a 9-year-old 
boy with congenital heart disease. It 
demonstrates phasic left anterior and 
left posterior fasicular block. Beats 
1, 2, 3 and 5 are conducted with left 
posterior fasicular block as manifested 


by right axis deviation and small q big R 
in leads II and III. Beats 4, 6 and 9 show 
left anterior fasicular block manifested 
by left axis deviation. The remaining 
beats are varying gradations of LAFB 
and LPFB. 

Reference 

Glasser SP, Flannery EP, Czamecki SW : Intermittent 
isolated left posterior fasicular block. Am J Med Sci, vol- 
ume 261, No 3 (March) 1971 






Professionsd 
treatment for 


professdon2d 

people. 

o 



ROYAL CROWN-COLA 


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OLDSMOBILE 

VETERANS & CAUSEWAY 

"The dealership that's different" 


February, 1974 — Vol. 126, No. 2 


61 




Guest Editorial 


Coronary Artery Disease — Risk Factor Screening and 
Modification — The Heart Association’s Program 
for Attacking the Nation’s Leading 
Health Problem 


Only 62 years have elapsed since 
Herrick’s classic contribution on myo- 
cardial infarction brought clinicopatho- 
logic correlation to coronary artery dis- 
ease. His article which appeared in the 
JAMA in 1912 is still relevant and is 
recommended reading.^ 

Our understanding of the disease and 
ability to handle the problems that it 
presents have multiplied. Although con- 
troversy continues as to the basic cause 
of atherosclerosis, we now have a work- 
ing knowledge of pathophysiology 
which, when applied to clinical situa- 
tions, produces gratifying results diag- 
nostically and therapeutically. 

We are able to recognize the disease 
earlier with stress testing. We are able 
to diagnose myocardial infarction more 
promptly with the aid of serum enzyme 
studies. There have been great advances 
in therapy, particularly in regard to the 
treatment of life threatening arrhyth- 
mias, both pharmacologically and elec- 
trically ; appropriate management of 
these, particularly in the coronary care 
unit setting, has reduced mortality. 
Coronary bypass surgery, although not 
without its critics, has had a definite 
impact on the disease in demanding our 
attention diagnostically because of the 
availability of dramatic and well publi- 
cized therapy, in a greater understand- 
ing of the pathologic anatomy and clini- 
cal manifestations of the disease and in 


Dr. Wilson is chairman of the Professional 
Education Committee, LHA. 


J. W. WILSON, JR., MD 
Shreveport 

creating a residue of surgeons with a 
cardiovascular orientation. 

Regrettably, all of these advances 
have had little impact on the overall 
picture of CHD. It remains the leading 
cause of death in this country and as 
Dr. Oalmann points out in Louisiana as 
well. We must think, then, not only 
diagnostically and therapeutically, but 
also prophylactically. We have been 
handed some elegant tools for this 
task by major contributions such as the 
“Framingham Study,” which identified 
certain variables common in those who 
subsequently developed coronary artery 
disease and thus provided us with “risk 
factors”. In this issue of the Journal, 
this has been explored from the stand- 
point of mass screening and also its 
application to office practice. The meth- 
ods prescribed are simple enough to be 
universally applicable. 

Critics may question the scientific 
value of some of these procedures; but 
with 600,000 people dying annually 
from a disease which may have existed 
for many years before becoming clini- 
cally manifest, the pragmatists among 
us cannot wait for the crystal clear 
opinions of the scientists, particularly 
when the procedures advised are not 
harmful, are relatively simple and are 
inexpensive. 

The modification of risk factors, how- 
ever, does present challenges from un- 
expected quarters. The management of 
“pre-disease” requires a shift in our 
orientation from crises’ care to preventa- 


62 


J. Louisiana State M. Soc. 


GUEST EDITORIAL 


tive medicine in a special sense; this is 
a shift that some of us find difficult to 
make. It also involves jousting with the 
windmills of patient motivation which 
can require the best of the art of 
medicine. Some question the practical- 
ity or even validity of the principle 
of devoting resources to the manage- 
ment of potential disease when medi- 
cine already is maximally committed to 
the management of acute problems. The 
heart association, however, agrees with 
Oliver Wendell Holmes: 

‘To guard is better than to heal — 

The shield is nobler than the spear** 

The Louisiana Heart Association has 
recently celebrated its 25th anniversary. 
During these years, it has had a visible 
impact on Louisiana medicine. It has 
educated our patients regarding heart 
disease and has granted over one million 


dollars in local research funds. It has 
supported and organized many pro- 
grams of professional education. In the 
past few years, there has been a shift 
in emphasis to programs of commu- 
nity service such as training and re- 
training in cardiopulmonary resuscita- 
tion. Presently a major program of mass 
hypertension screening is being mounted 
as a part of the risk factor screening 
program. 

As a voluntary health agency includ- 
ing a wide representation of many pro- 
fessional and lay disciplines, the heart 
association is well equipped to bring 
its resources to bear on specific prob- 
lems, unencumbered by other pressures. 
Every physician in Louisiana is asked to 
call on the heart association freely and 
to support and join it. 

Reference 

1. Herrick JB: Clinical features of sudden obstruction 
of the coronary artery. JAMA 59:201, 1912 


February, 1974 — Vol. 126, No. 2 


63 



IN A NUT SHELL... 

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offers total financial planning for the practicing physician. 

GROUP CONSULTANTS 

Administrator of Louisiana State Medical Society Group Insurance 
Programs. Disability Income, Major Medical, Life Insurance, Office 
Overhead Expense Insurance and Accidential Death and Dismember- 
ment. 

BYNUM, GRACE & KIRBY, INC. 

Offering complete Property and Casualty Insurance coverages. 

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Tax Shelters, Mutual Funds, Real Estate Partnerships, Bonds and other 
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Please inquire about our confidential review a 
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555 BUILDING • ST. TAMMNY STREET • P. O. DRAWER 66635 • BATON ROUGE, LOUISIANA 70806 

TELEPHONE (504) 926-6370 


J 


64 


J. Louisiana State M. Soc. 




ocioeconomic 



By LEON M. LANGLEY, JR. 


The New LSMS Group Professional Liability Insurance Program underwritten by the 
Hartford Insurance Company will be the topic of discussion on the March 7, 1974 
socioeconomic segment of the Doctor to Doctor Program. The two way talk- 
back system of the Louisiana Hospital Television Network will enable you to ask 
questions of the panelists. If you have any questions about this new member- 
ship benefit, be sure to watch this program. 

Sharp Increase in Professional Liability Insurance Premiums is sought by firms which 
write more than 90% of the medical malpractice insurance in the State of Mary- 
land. St. Paul Fire and Marine Insurance Companies are seeking an overall 59.7% 
increase, although the rise would be about 80% in some areas of Maryland. The 
Louisiana State Medical Society was successful in preventing this in the new 
LSMS group professional liability program by negotiating a contract with the 
Hartford Insurance Company. This contract allows Hartford to annually in- 
crease premiums by a maximum of 15% only after it is demonstrated to the 
LSMS that an increase is necessary. Johnson and Higgins, the group program ad- 
ministrator and consultant, monitors all statistics for the Society. 

Medicare Prevailing Charge Standards Will Be Open to the Public — including physi- 
cians — under a new rule adopted by HEW. The disclosure policy, which was 
opposed by the Social Security Administration, applies to “Screens” for both Part 
A and Part B. Individual physicians’ charges will remain confidential. The pol- 
icy became known when HEW said it would not appeal a US District Court 
judge’s decision that the secrecy of Part B charge standards is a violation of the 
Freedom of Information Law. Following the decision by Judge William Jones of 
Washington. D.C., HEW ordered Blue Shield to release Part B information for 
Maryland, Virginia and the District of Columbia to a medical writer who had 
been seeking full disclosure of Medicare operations. 

The screens vary widely from state to state and within states, and SSA had 
expressed concern that disclosure might result in demands for higher screens 
in some areas but that health industry price controls would hold down major 
changes. The LSMS has requested and recently received this information from 
Pan American Life, the Part B Medicare carrier for Louisiana. The LSMS will 
undertake a study of the Louisiana Medicare screens and will report the find- 
ings to the membership as soon as the study is completed. 

U.S. Infant Mortality Rate in 1972 was the lowest ever recorded in this Country, 18.2 
per 1000 live births. The rate is continuing its steady drop. In July of 1973, the 
latest month for which figures are available, it stood at 16.7. This was 8.7 % 
below the rate for the same month in 1972, which as just mentioned, was a very 
good year. 




February, 1974 — Vol. 126, No. 2 


65 


PRECISELY PROFESSIONAL 



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personally. Marc’s interior designers begin with a detailed evalua- 
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treatment and consultation. Clerical areas, filing, and storage 
are laid out for maximum utilization of space. Furniture and 
accessory selection is coordinated with wall covering, carpet- 
ing, and draperies predicated upon low maintenance durability. 

Have a professional design your office, save money and elim- 
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The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


SYNOPSIS 

LOUISIANA STATE MEDICAL SOCIETY 
EXECUTIVE COMMITTEE 
New Orleans, Louisiana 
December 20, 1973 

(Confirmation of Mail Vote) 

Approval — Minutes — Executive Committee 
August 16, 1973. 

Approval — Minutes — Educational and Re- 
search Foundation August 16, 1973. 

Approval — Active, Active Dues Exempt, Asso- 
ciate and Intern /Resident Membership (See 
Action Taken in re ADE). 

Provisional approval — Louisiana Cancer Cen- 
ter. 

Approval — Invitation for AMA to hold meet- 
ing in New Orleans. 

Approval — Recommendations of Committee on 
Chronic Diseases in re Chronic Renal Disease 
Guidelines. 

Reports 

President — Meetings recently attended; plaque 
presented to H. H. Hardy, Jr., MD for service 
as Chairman of House of Delegates. 

Secretary-Treasurer — LSMS and AMA mem- 
bership; AMA incentive program (See Other 
Matters Discussed) ; resolution from Legisla- 
ture in re First Aid Station services ; report 
that Congress on Occupational Health will not 
hold meeting in New Orleans; Annual Meeting 
plans; PSRO area designations (See Action 
Taken); Pelican lapel pins (See Action Taken). 

Board of Councilors — Professional cards car- 
ried in Journal (See Action Taken). 

Ad Hoc Committee on Insurance Claims — dis- 
agreement in re claims handled by Pan American 
Life Insurance Company; claims reports in con- 
nection with Blue Cross (See Other Matters 
Discussed). 

Committee on Chronic Diseases — Proposed 
meeting between Committee on Chronic Dis- 
eases and DHEW regional representative in re 
renal disease guidelines (See Action Taken). 

Legislative Consultant — Activities of Special 
Session of Legislature and CC ’73. 

Legal Counsel — Recently rendered legal opin- 
ions; participation of component societies in re 
projects in conflict with State Society policy 
(See Action Taken). 

LAMP AC — Presentation of PSRO film; LSMS 
support of film requested; State Society’s finan- 


cial support of film and possible IRS difficulties 
discussed (See Action Taken and ERF Action). 

AMA Delegates — Action at 1974 AMA Clinical 
Meeting reviewed (See Action Taken). 

Family Health Foundation — FHF information 
packet distributed. 

Socio-Economics — State Society insurance 
plans; seminar in re-establishment of medical 
practice. 

Action Taken 

Formulation of resolution in re Active Dues 
Exempt membership referred to Committee on 
Charter, Constitution and By-Laws. 

Strong protest in re PSRO area designations 
to be sent to Louisiana Congressional Delega- 
tion; staff to word formal protest. 

Purchase of 1,000 pelican lapel pins approved. 

Deletion of professional cards carried in Jour- 
nal referred to Journal Committee. 

Offer that DHEW regional representatives 
meet with Committee on Chronic Diseases rela- 
tive to renal disease guidelines accepted. 

Letter of thanks to be sent to Representative 
B. F. O’Neal, Jr. for interest in chiropractic 
situation. 

Letters of commendation to be sent to Dr. 
John P. Heard and Congressman Philip M. 
Crane for presentations in re PSRO at AMA 
meeting. 

All resolutions submitted in name of a com- 
ponent society be certified by secretary of parish 
society as being submitted and approved by that 
local society. 

Name of the LSMS be used in publicizing 
LAMPAC PSRO film within legal limitations; 
name of Society and the incorrect statements 
be amended; ownership to be transferred to 
LSMS-ERF. 

Dr. F. Michael Smith’s report on hospital 
economics, health care costs and influence of 
prepayment plans on American health care sys- 
tem referred to members of Executive Commit- 
tee for individual perusal. 

Disapproval of honorary membership for Dr. 
Roy T. Lester. 

Recommendation to be made concerning addi- 
tion of physician on competent authority team 
in re evaluation of children with school problems. 

Collection of national, state and local dues 
by component societies referred to Committee on 
Charter, Constitution and By-Laws. 

Secretary-Treasurer to write letter to local 


February, 1974 — Vol. 126, No. 2 


67 


ORGANIZATION SECTION 


telephone company concerning screening of physi- 
cians listed in yellow pages; matter to be brought 
to the attention of the State Board of Medical 
Examiners. 

Names of Drs. J. Morgan Lyons, Sam Hobson, 
Mannie D. Paine and Norton Voorhies submitted 
for vacancy on State Board of Medical Exam- 
iners. 

Affiliate membership for two oral surgeons 
referred to Committee on Charter, Constitution 
and By-Laws. 

Disapproval of recommendation that Execu- 
tive Committee call special session of House of 
Delegates to reconsider LSMS position on PSRO; 
suggestion to inform component societies in re 
position of State Society. 

Information to be carried in CAPSULES in re 
component societies abiding by State Society reg- 
ulations; action of House of Delegates to be con- 
sidered binding. 

Disapproval of recommendation that State 
Society oppose any group speaking for a medi- 
cal community unless such group has obtained 
support of majority of physicians in area and 


that the regulations under which such group 
acts have been submitted to component society 
in area involved. 

Communications 

Correspondence in re Blue Cross contracts pre- 
sented for information only. 

Opposition to Dr. H. M. Garrett’s appoint- 
ment to La. Air Control Commission presented 
for information only. 

La. Chapter of American Academy of Pedi- 
atrics in re opposition to Maternal Health Desk 
Cards accepted for information only. 

Green Clinic in re PSRO received for informa- 
tion only. 

Governor Edwards’ reply in re Charity Hos- 
pital in Lafourche Parish accepted for informa- 
tion only. 

Other Matters Discussed 

AMA incentive program; suggestion made that 
By-Laws of State Society be amended with re- 
gard to collection of dues by component societies. 

Information concerning claims reports and the 
furnishing of definite diagnosis and treatment 


At Your Service in 
The Peiican State 


In the region* named by LaSalle 
in honor of Louis XIV and 
sometimes called The Creole 
State because of its many 
descendants of early French and 
Spanish settlers . . . 



PHARMACEUTICAL DIVISION 

MARION 

LABORATORIES. INC. 

KANSAS CITY, WO. _64137 


is represented by . . . 



68 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


information by doctors; suggestion to carry in 
CAPSULES. 

Questionnaire concerning college and univer- 
sity health affairs previously referred to Com- 
mittee on Sports and College Medicine. 

Use of name of LSMS on HMO chart. 

Louisiana Pharmaceutical Association resolu- 
tion in re drug sampling. 

Action of Orleans Parish Medical Society in re 
insurance programs; OPMS President agreed 
that Orleans Parish members should be encour- 
aged to participate in LSMS program and that 
any misinformation should be corrected. 

Suggestion that reports submitted to House of 
Delegates without recommendations be received 
for filing, not accepted with approval. 

Proposed Board of Dermatopathology. 

Information in re prevailing charge standards 
under Part B of Medicare (to be received from 
Pan American). 

Minutes of Ad Hoc Committee to Study Qualco. 

SAMA-MECO program for 1974. 

Establishment of Child Protection Centers; 
suggestion that this would be a worthy project 
for the Auxiliary. 


Federal Regulations in re Utilization Review 
and advantages of direct billing. 

Suggestion that irtformation be obtained con- 
cerning area planning committees in state. 

ERF Meeting 

Certificates of deposit to be purchased with 
portion of funds received from P. H. Jones, M.D. 
estate. 

Appropriation of $10,000 for LAMPAC PSRO 
film project approved. 

Portrait of H. Ashton Thomas, M.D. accepted. 


HIGHLIGHTS OF HOUSE OF 
DELEGATES ACTIONS 
AMERICAN MEDICAL ASSOCIATION 
27th CLINICAL CONVENTION 
ANAHEIM, CALIFORNIA 
The AMA House of Delegates elaborated on its 
policy position on Professional Standard Review 
Organizations (PSRO) during the 27th Clinical 
Convention of the AMA in Anaheim, Dec. 1-5. 
The House also addressed itself to problems aris- 
ing from federal wage and price controls over 



Puts comfort 
in your prescription 
for nicotinic acid 

NICO-400 


February, 1974 — Vol. 126, No. 2 


69 


ORGANIZATION SECTION 


A powerful lot of people 
have been saving at 
Eureka since 1 884 



2525 Canal Street Phone 822-0650 
110 Belle Chasse Hwy. 

West Bank Division 
EUREKA HOMESTEAD SOCIETY 


health care providers, as well as numerous other 
issues of concern to physicians and the public. 

Meeting for a total of 14 hours and 36 min- 
utes, the House acted on 67 reports and 81 reso- 
lutions for a total of 148 items of business, the 
biggest agenda for a Clinical Session in recent 
years. 

Other issues considered ranged from malprac- 
tice problems to proposed improvements in health 
care delivery for migrant workers, and the 
method of election — and terms of service — of 
members of the Board of Trustees. 

A total of 10 resolutions concerning the PSRO 
Law were introduced during the clinical session, 
more than for any other item of business; this 
indicates the high degree of concern over the 
issues surrounding PSRO and professional peer 
review. 

PSRO’s 

Reference Committee A, which began its hear- 
ings on PSRO shortly before noon Monday, 
Dec. 3, heard more than four hours of testimony 
from physicians expressing various shades of 
opinion, and did not complete its preliminary 
report until the early morning hours of Tuesday. 

After more than two hours of additional dis- 
cussion on PSRO’s on Wednesday, the House of 
Delegates adopted Report EE of the Board of 
Trustees, as amended, in lieu of the various reso- 
lutions which had been submitted. The report 
summarized PSRO developments to date, and out- 
lined previous AMA policy in confronting the 
PSRO issue. 

The House adopted the following amendment 
to be inserted on page 3, line 16, of Report EE 
of the Board of Trustees and Council on Medical 
Service: 

The AMA affirms the following principles: 

1. That the medical profession remains firm- 
ly committed to the principle of peer review, un- 
der professional direction, and 

2. That medical society programs of proven 
effectiveness should not be dismantled by PSRO 
implementation, and 

3. That the Association suggests that each 
hospital medical staff, working with the local 
medical society, continue to develop its own peer 
review, based upon principles of sound medical 
practice and documentable objective criteria, so 
as to certify that objective review of quality and 
utilization does take place; to make these review 
procedures sufficiently strong as to be unassail- 
able by any outside party or parties ; and that the 
local and state medical societies take all legal 
steps to resist the intrusion of any third party 
into the practice of medicine, and 

4. That this House of Delegates, as individual 
physicians and through the Board of Trustees 
and its Council on Legislation, work to inform 
the public and legislators as to the potential dele- 

J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


terious effects of this law on the quality, con- 
fidentiality and cost of medical care; and the 
hope that the Congress in their wisdom will re- 
spond by either repeal, modification, or interpre- 
tation of rules which will protect the public. 

The considered opinion of this House of Dele- 
gates is that the best interests of the American 
people, our patients, would be served by the re- 
peal of the present PSRO legislation. It is also 
believed that this is consistent with our long- 
standing policy and opposition to this legislation 
prior to passage. 

In adopting the above amendment, the House 
made special note that the last paragraph of 
Report EE remains the same. The last paragraph 
reads : 

The considered opinion of the Board of Trus- 
tees and the Council on Medical Service is to 
recommend to the House of Delegates that the 
AMA continue to exert its leadership and sup- 
port constructive amendments to the PSRO 
law, coupled with continuation of the effort to 
develop appropriate rules and regulations. (Re- 
port EE adopted as amended) 

Phase IV Wage-Price Controls 

Four resolutions and two reports were intro- 
duced dealing with discriminatory Phase IV 
Wage-Price Controls on health care providers and 
institutions. The House approved a Board of 
Trustees Report announcing AMA support for 
the American Hospital Association in its battle 
against proposed controls over acute care hos- 
pitals. Delegates also adopted a substitute reso- 
lution which directs the AMA to continue, “as a 
matter of high priority,” to seek relief for physi- 
cians from wage-price controls “using all avail- 
able administrative resources,” and that “the 
Board of Trustees be authorized to institute ap- 
propriate legal action when so advised by legal 
counsel.” 

Address of the President, Russell B. Roth 

In opening-day remarks which drew a stand- 
ing ovation from the House, Dr. Russell B. Roth, 
President of the AMA, discussed some of the 
complex issues surrounding peer review and Pro- 
fessional Standards Review Organizations. 

The only way to effectively assure high qual- 
ity care is through professional peer review, Dr. 
Roth said, because “ultimately, excellence of 
medical care is determined by the competence, 
the motivation, and the integrity of the physician 
who provides it.” 

The problem with most lay-initiated peer re- 
view proposals is that they are based on the mis- 
taken premise that good health care can be 
provided through improved delivery systems or 
institutionalization, according to Dr. Roth. 

Since the delivery of most medical care takes 
place outside the hospital, and because the quality 


of care is not something that can be measured in 
dollars of cost or hours of time, however, peer 
review standards such as those proposed under 
PSRO will be difficult to establish, he said. 

“Regardless of how one may derive standards 
and norms, the matter of judging conformity and 
of evaluating exceptions and divergencies is a 
peer professional problem. 

“We should reflect that a medical school is re- 
garded as good because it is adjudged to be so 
by physician graduates, physician faculty mem- 
bers, and physician contemporaries.” 

Dr. Roth added that more attention will be 
paid to evidence that physicians are keeping 
abreast of medical progress and are maintaining 
their medical competence, but he said that, “This 
too will undoubtedly be accomplished by peer 
evaluation.” 

Dr. Roth did not take sides on the PSRO ques- 
tion, but spoke for “the good and useful things 
which we may do to identify high quality of care, 
and of the immense difficulties in doing this 
well.” 

But Dr. Roth concluded that, “If solutions 
were to come easily it would not be a challenge — 
and challenge it is. In the meantime the nation 
will be well advised to put its confidence in the 
competence, the integrity and the motivation of 
the medical profession.” 

Remarks of Charles C. Edwards, MD, 
Assistant Secretary for Health, 
Department of HEW 

The leadership of organized medicine is indis- 
pensable to the resolution of today’s pressing 
health problems, according to Dr. Charles C. 
Edwards, Assistant Secretary for Health, U.S. 
Department of Health, Education and Welfare, 
who addressed the House at the opening of its 
Tuesday session. 

The AMA’s Medicredit Bill, and its national 
policy proposal for the collection and distribution 
of blood (a policy endorsed by the House during 
the Tuesday session) are evidence of AMA initia- 
tive and leadership. Dr. Edwards said. 

Discussing PSRO, he said that many of the 
complex problems created by the law can be 
solved if the government has the continued sup- 
port of the PSRO Council, the AMA, and a num- 
ber of other professional organizations that recog- 
nize both the problems and the potential of 
PSRO. 

He pointed out that virtually every institution 
— governmental or private — is being subjected 
to the scrutiny of the public, and that significant 
changes are taking place in our society. 

According to Dr. Edwards, the message implicit 
in PSRO is clear: “The medical profession is 
being asked to solve its own problems, to work 
collaboratively with government when their joint 


February, 1974 — Vol. 126, No. 2 


71 


ORGANIZATION SECTION 


efforts are needed, but to maintain the indepen- 
dence that has permitted it to make a great con- 
tribution to the health of the American people.” 

To completely turn back from this course, he 
said, would be to give up by default “the oppor- 
tunity to help determine the future of the Amer- 
ican system of health care.” 

Presentation of Awards 

Benjamin Rush Bicentennial Award — Otis 
Bowen, MD, the Governor of Indiana, was award- 
ed the Dr. Rodman E. Sheen and Thomas G. 
Sheen Benjamin Rush Bicentennial Award for 
Citizenship and Public Service. Presented by Dr. 
Russell B. Roth, AM A President, the award con- 
sists of a plaque and a $5,000 honorarium. 

Governor Bowen, who has served in numerous 
community, civic and public service capacities 
during his career, said the $5,000 contribution 
will be used to start a no-interest educational 
loan fund for medical students willing to set up 
practice in an Indiana town or city with a physi- 
cian shortage. 

Awards for Service — William F. House, MD, 
DDS, of Los Angeles, was selected by the House 
as the recipient of the Distinguished Service 
Award. A specialist in otology. Dr. House directs 
the largest graduate and postgraduate teaching 
program in otology in the world. 

He completed his internship and residency at 
the Los Angeles Hospital in 1955, and was certi- 
fied by the American Board of Otolaryngology in 
1953. 

Nathan J. Stark, Kansas City, a Senior Vice- 
President of Hallmark Cards, Inc., and Chairman 
of the Board and Chief Executive Officer of the 
Crown Center Redevelopment Corporation in 
Kansas City, was selected to receive the Layman’s 
Citation for Distinguished Service, the highest 
award the AMA can bestow on a layman. 

Mr. Stark has served on a number of boards 
and organizations involving health care, includ- 
ing the Advisory Council of the Missouri Region- 
al Medical Program, the Health Insurance Bene- 
fits Advisory Council of the U.S. Department of 
HEW, and was chairman of the Committee on 
Hospital Governing Boards of the American 
Hospital Association. 

Both of these awards will be presented during 
the 1973 Annual Meeting in Chicago. 

Reappointed to Coordinating Council on 
Medical Education 

Merrill O. Hines, MD, New Orleans, was re- 
appointed by the House to the Coordinating 
Council on Medical Education. Dr. Hines, a clin- 
ical professor of surgery at Tulane, is a member 
of the Advisory Committee on Graduate Medical 
Education of the Council on Medical Education, 


and is an AMA Delegate from the Section on 
Colon and Rectal Surgery. 

Summary of Actions of the 
H ouse of Delegates 

Because of the wide-ranging nature of the ac- 
tions taken by the House of Delegates, and for 
the sake of clarity, this summary will be divided 
into four subject areas with appropriate sub- 
headings: Physicians and Hospitals and Medical 
Schools; Physicians and the Public; Association 
and Internal Matters of the House; and Miscel- 
laneous. (Note: The items mentioned under each 
subject area are not all-inclusive, but include only 
the more significant actions taken.) 

Physicians and Hospitals and 
Medical Schools 

Pre-Admission Certification — The House con- 
sidered two resolutions dealing with proposed 
government regulation which would impose a 
hospital pre-admission certification program for 
patients under Medicare. Resolution 48, adopted 
by the House, directs the AMA to take all steps 
necessary to prevent enactment of regulations 
mandating hospital pre-admission certification, 
and to determine whether such regulations would 
be in violation of Medicare law. 

Another Resolution, No. 68, which would have 
the AMA request the Secretary of HEW not to 
allow the publishing of pre-admission certifica- 
tions in the Federal Register, and also would 
have the AMA seek Congressional support for 
this position, was referred to the Board of Trust- 
ees and the Council on Legislation. 

Funding Medical Education — Report C of the 
Board of Trustees, which outlines continuing 
AMA efforts to secure balanced funding for med- 
ical education and research, was adopted by the 
Delegates. The report describes several studies 
of the cost of medical education and its relation 
to the cost of medical care that are presently 
underway, and points out that the Council on 
Medical Education is closely monitoring the re- 
sults of such studies with a view toward future 
actions. 

Quality Assurance Program — After consider- 
able discussion, the House adopted a resolution 
that offers the American Hospital Association 
the cooperation of the AMA in deliberations on 
the AHA’s Quality Assurance Program. The 
AMA will seek the elimination of features it con- 
siders undesirable. A final resolve puts the AMA 
on record as disapproving of QAP in its present 
form. 

Problems with Third-Party Rounds — A report 
of the Council on Medical Education and the 
Council on Medical Service with suggestions to 
minimise problems arising from the use of pri- 
vate patients in teaching programs was adopted 
by the House, and referred to the Judicial Coun- 


72 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


cil and the AMA Legal Department, with instruc- 
tions to file a report through the Board of Trust- 
ees for the 1974 Annual Meeting. 

Intern and Resident Matching Program — The 
House adopted Report F of the Board of Trustees 
which recommends that the present National 
Intern and Resident Matching Program remain 
in effect. Two resolutions introduced at the 1973 
Annual Session had proposed that the National 
Matching Program abandon its “all or nothing” 
policy. Testimony before Reference Committee C, 
which considered the matter, indicated students 
endorsed the Board Report. The committee added 
that further study of the matching program is 
being conducted by the Liaison Committee on 
Graduate Medical Education and the Coordinat- 
ing Council on Medical Education. 

Physicians and the Public 

Health of Migrant Workers — Development of a 
possible nationwide health insurance program for 
migrant workers is one of several proposals con- 
tained in Council on Medical Service Report C 
approved by the House. 

The report states that such an insurance pro- 
gram is possible, and adds that there is a need 
for migrant health advocates, who would be paid 
for their services rather than be volunteers. 

Under action taken by the House, the Council 
on Medical Service is instructed to develop a ver- 
sion of such an insurance program. 

Confidentiality of Records — The House adopted 
Report D of the Council on Medical Service which 
describes efforts to find practical solutions to 
problems related to maintaining the confidential- 
ity of patient records. The House further in- 
structed the Council to prepare model legislation 
to preserve confidentiality as a guide to possible 
state legislation. Also adopted was Resolution 41 
which puts the AMA on record in opposition to 
violation of the confidentiality of patient records 
by government agencies under all circumstances. 

Alcoholism — Under Resolution 30 adopted by 
the House, the medical treatment and admission 
of alcoholics would be improved. The resolution 
recommends to the American Hospital Associa- 
tion that it urge member-hospitals to liberalize 
admission policies for alcoholics where necessary; 
urges physicians to abstain from using the names 
of other pathological conditions in lieu of alco- 
holism, urges the Joint Commission on Accredi- 
tation of Hospitals to implement the intent of the 
Resolution as one of its requirements for ap- 
proval, and urges insurance companies and pre- 
payment plans to remove unrealistic coverage 
limitations for treatment of alcoholics. 

Health Care of the American Indian — The 
House adopted and referred to the Board of 
Trustees for further action a Report by the Coun- 
cil on Medical Service and its Committee on 


Health Care of the Poor regarding proposed im- 
provements in the Indian Health Service. The re- 
port summarized the total picture of Indian 
health, and contained recommendations on how to 
improve the Indian Health Service programs of 
the federal government. 

National Blood Program — The concept of the 
proposed AMA plan to implement the govern- 
ment’s National Blood Policy by organizing blood 
banks and transfusion facilities within a national 
system that retains regional and local responsi- 
bilities and authority was endorsed by the House. 
The AMA plan was contained in Board of Trust- 
ees Report Z adopted by the Delegates. 

Definition on Death — Because of complex legal 
ramifications, the House adopted a policy position 
that at present the statutory definition of death 
is not desirable or necessary, that state medical 
associations urge their legislators to postpone 
enactment of definition of death statutes. The 
House also affirmed the following statement: 
“Death shall be determined by the clinical judg- 
ment of the physician using the necessary avail- 
able and currently accepted criteria. 

The Dying Patient — The House adopted the 
following statement to serve as a guideline for 
physicians confronted with ethical problems re- 
lated to euthanasia (mercy killing) and death 
with dignity: 

“The intentional termination of the life of 
one human being by another — ^mercy killing — is 
contrary to that for which the medical profes- 
sion stands and is contrary to the policy of the 
American Medical Association. 

“The cessation of the employment of extra- 
ordinary means to prolong the life of the body 
when there is irrefutable evidence that biolog- 
ical death is imminent is the decision of the 
patient and/or his immediate family. The ad- 
vice and judgment of the physician should be 
freely available to the patient and/or his im- 
mediate family.” 

Association and Internal Matters of the House 

Terms of Service of Trustees — Proposed 
amendments to the by-laws which would have 
limited members of the Board of Trustees to a 
maximum of two full terms of three years each 
were not adopted by the House. The action re- 
tains the present provision allowing trustees to 
serve three full terms of three years each. 

Method of Electing Trustees — In a related 
action, the Delegates approved two other resolu- 
tions which will allow candidates for the Ameri- 
can Medical Association Board of Trustees to run 
at large rather than for designated “slot” posi- 
tions as is presently done. One of the resolutions 
adopted outlines the methods to be followed in 
at-large election of trustees, while the other deals 
with any necessary changes in the by-laws. 


February, 1974 — Vol. 126, No. 2 


73 


ORGANIZATION SECTION 


To be considered further at the 1974 Annual 
Meeting. 

Specialty Representation in House — The House 
took several actions related to direct representa- 
tion of national medical specialty societies in the 
House of Delegates. The House adopted a report 
of the Council on Constitution and Bylaws call- 
ing for a thorough study of the proposal, includ- 
ing an open hearing at the 1974 Annual Meeting. 
Two resolutions, both calling for the rejection of 
direct representation by the specialty societies, 
were referred to the Council on Constitution for 
consideration in its study. 

Professional Liability — Report DD of the Board 
of Trustees, which summarizes the development 
of the new Medical Liability Commission formed 
by the AMA, and AHA, and several national 
medical specialty organizations, was endorsed by 
the House. Delegates further directed that the 
Board of Trustees “grant the highest priority for 
financial and organizational support” for the 
commission. 

The Board of Trustees will request that the 
Commission give some priority to basic research 
in the field of medical liability, and will urge the 
present Secretary of HEW to consult and cooper- 
ate with the commission. 

The action also puts the House on record as 
urging all delegates, state and local medical asso- 
ciations, and other medical organizations to sup- 
port the new commission, and to submit to it any 
appropriate comments, suggestions or ideas for 
easing malpractice problems. 

Renal Dialysis — Acting on Report J of the 
Council on Medical Service and on several resolu- 
tions, the House adopted a strong policy position 
on renal dialysis and transplant procedures under 
Medicare. The report and resolutions objected to 
the “interim regulations” issued by the federal 
government in respect to renal dialysis and trans- 
plant under Medicare, since the regulations estab- 
lish what is tantamount to a maximum fee sched- 
ule on a national basis for professional services, 
and in effect dictate on a national scale the 
method by which certain kinds of medical care 
are rendered. 

Under actions taken by the House, the AMA 
will strongly protest — and seek to rescind — the 
interim regulations; request that the federal gov- 
ernment return to existing systems of determin- 
ing medical necessity for treatment and setting 
fees; and — with consultation from concerned 
medical specialty societies — work with the gov- 
ernment in redrawing the interim regulations. 

Miscellaneous Actions of the House 

In miscellaneous actions, the House: 

— Referred to the Council on Medical Service a 
resolution urging the AMA to oppose wide differ- 
ences in fees for medical services performed by 
equally qualified physicians who practice in dif- 


ferent geographic areas of a state . . . 

— Adopted a report recommending that sum- 
maries of court decisions on informed consent be 
made available to physicians on request, rather 
than the compilation of model guidelines since 
court interpretations of informed consent vary 
from one jurisdiction to another . . . 

— Adopted a substitute resolution calling for 
the Board of Trustees, the Interns and Residents 
Business Section, the Council and Medical Ser- 
vice, and the Council on Medical Education, to 
develop principles and guidelines for agreements 
between House staff and their institutions, and 
to explore the development of a model contract 
for use by institutions with graduate medical 
education programs . . . 

— Approved a proposal that the 1977 Annual 
Meeting be held in San Francisco and the 1977 
Clinical Session in Chicago . . . 

— Adopted a report of the Council on Medical 
Service outlining progress made in persuading 
the Aetna Life and Casualty Company to limit 
the use of its surgical predetermination form . . . 

— Endorsed Board of Trustees action in sup- 
porting the enactment of legislation for medical 
devices . . . 

— Referred to the Officers of the Interns and 
Residents Business Section and the Board of 
Trustees a resolution seeking AMA support for 
an exemption from federal taxes of the first 
$3,600 of annual income paid post-doctoral train- 
ees by institutions accredited by the AMA Coun- 
cil on Medical Education . . . 

— Filed a report stressing the record growth of 
the American Medical Association Education and 
Research Foundation . . . 

— Adopted a substitute resolution encouraging 
the observance of due process in disputes involv- 
ing interns and residents and the institutions in 
which they work. 




Physician Wanted 

WONDERFUL OPPORTUNITY for physi- 
cian in private practice of medicine. Chief 
of Emergency Medical Services Department 
seeing 18,000 patients per year. 200-1- bed 
hospital in beautiful semi-resort city on 
fast growing LA Gulf Coast. Fee for ser- 
vice, with initial guarantee. For immediate 
reply, send resume to Stephen B. Collins, 
Executive Director, or Dr. Avery L. Cook, 
President, Medical Staff, Lake Charles Me- 
morial Hospital, P. 0. Box M, Lake Charles, 
LA 70601, or call collect (318) 478-1310. 


74 


J. LOUISIANA State M. Soc. 



wjicj 



CALENDAR 


PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascenston 

Third Tuesday of every month 


Calcasieu 

Fourth Tuesday ot every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday of every month 

Baton Rouge 

Jackson-Lincoln-Union 

Third Tuesday of every month 
except summer months 


Jefferson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday ot every other mo'nth 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday ot every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 


every month 

Independence 

Terrebonne 

Third Monday of every month 


Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday ot every month 



POSTGRADUATE COURSE IN 
PEDIATRICS 

The 23rd Annual Postgraduate Course in 
Pediatrics of The University of Texas Medical 
Branch will be held in Galveston, Texas, March 
14 and 15, 1974. The course will be entitled “Pe^ 
diatric Potpourri” with guest lecturers Paul 
Wehrle, MD, Elliott Ellis, MD, and Marvin Com- 
blath, MD. 

This program is acceptable for 12 prescribed 
hours by the American Academy of General 
Practice and registration fee will be $75.00. Fut- 
ther information will be furnished by Lillian H. 
Lockhart, MD, Chairman, Pediatric Postgraduate 
Committee, The University of Texas Medical 
Branch, Galveston, Texas 77550. 


COLLEGE OF SURGEONS TO 

HOLD SPRING MEETING IN HOUSTON, 
MARCH 25-28, 1974 

The American College of Surgeons will hold 
its second annual four-day Spring Meeting in 
Houston on Monday, March 25 through Thursday, 
March 28, 1974, at the Albert Thomas Conven- 
tion Center and the Hyatt Regency Hotel. 

The meeting will provide eight postgraduate 
courses, some of which will feature plenary ses- 
sions, followed by workshops to facilitate partici- 
pation and discussion. A surgeon may choose 
one of four courses during the first two days of 
the meeting, and select another from four other 
offerings in the second two days. 

The nine-hour postgraduate courses will be 
supplemented by two days of symposia, panels, 
lectures and motion pictures. 


Industrial exhibits will be open in the Albert 
Thomas Convention Center on Monday, Tuesday 
and Wednesday, March 25-27, 1974, from 9:30 
a.m. to 5 p.m. 

Fee for the postgraduate courses, approved by 
the American Medical Association for credit as 
continuing education courses, is $40.00 for all 
registrants, manual included. Registration for 
this meeting is a prerequisite for registering in 
the postgraduate courses. 

Registration for the meeting will be free of 
charge to Fellows of the College whose dues are 
paid through 1973, members of the ACS Creden- 
tials Groups, and surgical residents. Non-Fellows, 
applicants for Fellowship and Fellows whose dues 
have not been paid, pay $50.00. Non-Fellows in 
the Federal Services (full-time) pay $30.00. 

Registered nurses and interns who present 
proper credentials may register free of charge 
for the general sessions and exhibits, but are not 
eligible for the postgraduate courses. 

Housing and registration forms are available 
from the ACS, 55 East Erie Street, Chicago, Illi- 
nois 60611. 


REFRESHER COURSE IN CARDIAC 
RADIOLOGY 

This course will be presented by the North 
American Society for Cardiac Radiology, to be 
held in the Royal Orleans Hotel, New Orleans, 
Louisiana, March 6 to 9, 1974. Topic: Cardiac 
radiology. Morning lectures and afternoon semi- 
nars on March 7, 8, 9. Fee: $185. Contact: Erik 
Carlsson, MD, Secretary-Treasurer, North Amer- 
ican Society for Cardiac Radiology, University of 
California, San Francisco CA 94143. 


February, 1974 — Vol. 126, No. 2 


75 


MEDICAL NEWS 


NATIONAL RESPIRATORY CARE COURSE 
SCHEDULED FOR NEW ORLEANS 

The Sixth Annual Postgraduate Course on 
“Newer Concepts of Care for Patients with Re- 
spiratory Disease” will be presented March 22- 
29, 1974, in New Orleans by the American Lung 
Association of Louisiana, Inc,, formerly known 
as the Louisiana TB and Respiratory Disease As- 
sociation, Inc. 

National cosponsors for the course include the 
American Thoracic Society, the American Nurses 
Association, the American Association for Inhala- 
tion Therapy, and the National League for Nurs- 
ing Advisory Service to the American Lung As- 
sociation. 

The course will be presented in the auditorium 
of Louisiana State University Medical Center, 
School of Medicine and is designed for nurses, 
respiratory therapists, pulmonary function tech- 
nicians, physical therapists and other interested 
allied health personnel. 

Special interest is devoted to the respiratory 
care “team” and physicians in the field of respi- 
ratory care are encouraged to attend with their 
staff workers, the nurse, the therapist, and the 
technician. 

Russell C. Klein, MD, course chairman, said 
that tuition for the five-day course will be $85.00. 
As in past years, some scholarships for assistance 
with tuition and transportation are available at 
local Christmas Seal Associations around the 
United States, Dr. Klein advises. 


THIRD ANNUAL FLAME-FREE NATIONAL 
DESIGN CONFERENCE 

The Third Annual Flame-Free National Design 
Conference, conducted under the auspices of The 
Southern Burn Institute, Baton Rouge, will be 
held in Atlanta, Georgia on March 13-15, at 
The Marriott Hotel. 

Further information regarding this confer- 
ence may be obtained by contacting Charles H. 
Baughman, MD, 3849 North Boulevard, Suite 
104, Baton Rouge, Louisiana 70806. 


LOUISIANA DOCTOR QUOTED IN JAMA 

The A.M.A. Journal of January 21, 1974, 
page 328, quotes an excerpt of a letter written 
by Dr. Arthur Pitchenik of Lafayette, La., 
which is noteworthy. He advises young physi- 
cians to select internship according to oppor- 
tunity to contribute to the relief of the patients’ 
suffering, rather than to yield to inducements 
of better salary and working conditions. 


WINE AND BEER BENEFIT MANY 
ELDERLY PATIENTS 

Wine and beer in moderation are good for the 
physical and emotional ills of elderly patients, 
says an editorial in the November 12, 1973, issue 
of the Journal of the American Medical Associa- 
tion. 

Thomas B. Turner, MD, of The Johns Hopkins 
University School of Medicine, Baltimore, cites 
in the editorial a number of studies showing 
beneficial effects of a bottle of beer or a glass 
of wine among patients in nursing home situa- 
tions. 

The therapeutic effect of mild alcoholic drinks 
is considerably enhanced if the beverages are 
given in a pleasant group situation. Dr. Turner 
says. In one study the patients had their drinks 
in a room equipped like a pub, where they could 
visit and chat while imbibing. 

A group of 34 senile men in one situation were 
given a bottle of beer daily. After two months 
the whole atmosphere of the ward had changed. 
The number of incontinent men dropped from 26 
to 9 ; jacket restraint required in 26 before the 
new regimen was required in only 4 afterward; 
the number of ambulatory patients rose from 
7 to 25. 


ADVANCED CONTINUING EDUCATION 
WORKSHOP “PLASTIC SURGERY 
OF THE AGING FACE” 

The Department of Otolaryngology, Abraham 
Lincoln School of Medicine of the University of 
Illinois (in cooperation with the American Acad- 
emy of Facial Plastic and Reconstructive Sur- 
gery, Inc.) will present a multidisciplinary work- 
shop in facial plastic surgery June 1 through 5, 
1974. M. Eugene Tardy, Jr., MD, is chairman of 
the five-day workshop. 

The course will provide participants an oppor- 
tunity to enhance and refine their knowledge and 
diagnostic skills in analyzing, evaluating and 
managing patients presenting problems of facial 
aging. Topics for consideration include blepharo- 
plasty, dermabrasion, facelift, browlift, chemex- 
foliation, local pedicle flaps and scar camouflage. 
Live and videotaped television coverage of sur- 
gical techniques will be offered in addition to 
panel discussions by the distinguished local and 
national faculty members. 

Interested physicians should write to the De- 
partment of Otolaryngology, Eye and Ear In- 
firmary, 1855 West Taylor Street, Chicago, Illi- 
nois 60612. 


76 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


$6.00 Per Annum, $1.00 Per Copy TVTA'PP'H' 1 QT/l Published Monthly 

Vol. 126, No. 3 IVliArvC^Xl, 1700 Josephine Street, New Orleans, La. 70113 


Surgical Treatment of Primary Thrombosis of the 
Subclavian-AxUlary Vein* 

• A patient is presented who had primary venous thrombosis of the 
subciavian-axillary vein. A venogram illustrated obstruction near the 
costoclavicular area and first rib. These structures were partially 
resected after two attempts of phlebothrombectomy failed. The 
outlet space was then adequate, and the swelling which had been 
present in the patient's arm subsided. 


THIS case report illustrates aggressive 
^ surgical management of primary sub- 
clavian-axillary vein thrombosis. 

The syndrome of thrombosis of the sub- 
clavian axillary vein has been called effort 
thrombosis, costoclavicular compression, 
Paget-Schroetter syndrome, idiopathic 
thrombosis, and stress syndrome. “Pri- 
mary thrombosis of the subclavian axil- 
lary vein is of uncertain origin, resulting 
in proximal arm swelling, discomfort on 
use and prominence of engorged collateral 
veins in the upper arm and chest.”^ A 
poorly appreciated disability may result 
from conservative management.^ 


* Second Place, Dean Echols Award for Case 
Reports, Alton Ochsner Medical Foundation, New 
Orleans. 

t From the Department of Surgery, Ochsner 
Clinic and Ochsner Foundation Hospital, New 
Orleans, Louisiana. 

f St. Francis Hospital, Monroe, Louisiana. 
Reprint requests to John L. Ochsner, MD, 
Ochsner Clinic, 1514 Jefferson Highway, New 
Orleans, Louisiana 70121. 

March, 1974— Vol. 126, No. 3 


J. P. HUGHES, MDf 
JOHN L. OCHSNER, MDf 
DANIEL W. SARTOR, MDij: 
New Orleans 

Ceise Report 

A 37-year-old white male truck driver was 
hospitalized at the Delhi Clinic in Delhi, Louisi- 
ana on January 22, 1973. He complained of 
marked painless swelling for 24 hours in the right 
upper extremity. He was treated with heparin 
(500 mg intravenously every four hours), heat, 
rest, and elevation for 48 hours. He was trans- 
ferred to the St. Francis Hospital in Monroe, 
Louisiana. A venogram of the median basilic vein 
illustrated an intraluminal block of the right sub- 
clavian vein. There was poor collateral circula- 
tion around the subclavian-axillary obstruction 
(Fig 1). 

Exploration of the axilla was performed. A 
transaxillary approach was used to expose the 
axillary vein and first rib. The axillary vein was 
opened transversely, and a clot was removed 
proximally and distally. Fogarty venous throm- 
bectomy catheters were passed proximally meet- 
ing some obstruction near the costoclavicular rib 
area. The scalenus anticus and medius were di- 
vided and the first rib was removed. The pleura 
was not entered. Postoperatively the swelling in 
the arm and hand remained, and a second veno- 
gram was performed on January 26, 1973. A 
comnlete obstruction was found at the costocla- 
vicular plane (Fig 2) medial to the one noted on 
the first study. 

77 


PRIMARY THROMBOSIS— HUGHES, ET AL 



Fig 1. Venogram of the median basilic vein 
showing an intraluminal block of the right sub- 
clavian vein with poor collateral circulation. 



Fig 2. Second venogram showing complete 
obstruction at the costoclavicular plane. 


A sternal splitting incision was used to visual- 
ize the right innominate vein and superior vena 
cava. These vessels had no clot. We were un- 
able to pass a Fogarty catheter distal to the 
innominate venotomy. The skin incision was 
extended over the right clavicle. The proximal 
one-fourth of the clavicle was resected, and the 
compression obstruction on the subclavian vein 
was relieved. The subclavian vein was dissected 
from under the bed of the clavicle, opened, and 
the organized clot was removed. Good flow re- 
turned to the vein and the venotomy was closed. 
Postoperatively the patient became quite ill with 
high fever and pneumonitis, but he responded 
well to treatment. Heparin anticoagulation 
therapy was maintained for one week and then 
changed to sodium warfarin (Coumadin®). The 
edema and distended vascular areas disappeared. 


Discussion 

Swinton, et al,’ found 500 cases of pri- 
mary thrombosis of the upper extremity 
reported in the literature. Its etiology is 
unknown but it is sometimes caused by 
local compression and stasis factors-'*-^ as it 
was in our patient. The clinical manifes- 
tations are usually pain, swelling, and 
venous prominence. The hand becomes 
swollen after massive proximal edema is 
present. The pulses do not change. Rest- 
ing, wrapping, and elevating the arm may 
give some relief. The diagnosis is made 
by history and physical examination. Up- 
per extremity venograms most commonly 
show localized blocks in the subclavian- 
axillary junction between the first rib and 
the clavicle. Collateral venous patterns 
usually arise through the cephalic trans- 
verse, scapular transverse, cervical-jugu- 
lar vein route or through the thoracic, 
intercostal, internal mammary vein route. 
Our patient had very little collateral cir- 
culation (Fig 2). 

Chronic disability, lasting for years, 
may result from conservative management 
of primary subclavian-axillary vein throm- 
bosis.^ Successful thrombectomy has been 
reported by Adams, et al,- Mahorner, 
et al,"‘ and Drapanas and Curran.® Venog- 
raphy is essential before the throm- 
bectomy. Mahorner, et al,® advocate com- 
bining thorough exploration of the outlet 
spaces with thrombectomy and removal of 
offending obstructive outlet structures. 
This worked well with our patient who 
had a normal arm without edema two 
weeks postoperatively. 

Ackno wled gement 

Special thanks are due Theresa Setze, 
Alton Ochsner Medical Foundation, New 
Orleans, and Kay Hancock, Conway Char- 
ity Hospital in Monroe, Louisiana. 

References 

1. Swinton NW Jr, Edgott JW Jr, Hall RJ : Primary 
subclavian-axillary vein thrombosis. Circulation 38:7.17. 
1968 

2. Adams JT, McEvoy RK, DcWecse JA: Primary 

deep venous thrombosis of upper extremity. Arch Surg 
91 :29, 1965 


78 


J. Louisiana State M. Soc. 


PRIMARY THROMBOSIS— HUGHES, ET AL 


3. Adams JT, DeWeese JA, Mahoney EB, et al : Inter- 
mittent subclavian vein obstruction without thrombosis. 
Sui'gery 63:147, 1968 

4. Ochsner A, DeBakey M: Thrombophlebitis: Role of 
vasospasm in production of clinical manifestations. JAMA 
114:117, 1940 


5. Mahorner H, Castleberry JW, Coleman WO: At- 
tempts to restore function in major veins which are sites 
of massive thrombosis. Ann Surg 146:510, 1957 

6. Drapanas T, Curran WL: Thrombectomy in treat- 
ment of “effort” thrombosis of axillary and subclavian 
veins. J Trauma 6:107, 1966 



March, 1974 — VOL. 126, No. 3 79 



Louisiana State Medical Society 

EUROPEAN ADVENTURE 


A VACATION AS QUAINT, 
ROMANTIC AND COLORFUL 
AS EUROPE ITSELF. 

Join us for two weeks on a relaxing, 
do-as-you-please holiday in Switzer- 
land, Germany and Austria. Every- 
one should have at least one adven- 
ture a year, and this can be yours 
. . . Cosmopolitan Zurich, historic 
Berlin, nostalgic Vienna. Alpine 
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tax and service 


Includes: Direct chartered jet flights. 
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DEPARTING NEW ORLEANS 
SEPTEMBER 14, 1974 


Send to: 

LOUISIANA STATE MEDICAL SOCIETY 
1700 Josephine St. 

New Orleans, La. 70113 

Enclosed is my check for $ 

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the total deposit will be refunded if it be- 
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Adventure membership at least 60 days be- 
fore departure, when final payment is due. 


NAMES 


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Make Your Reservations Now — Space Limited 



A Review of Family Health’s Latest Evaluation 
of the Demographic Impact of the Louisiana 
Family Planning Program* 

• The authors indicate that they have devoted most of this article 
to a discussion of new procedures with special emphasis on "parity 
components" and "excess births." 


Background 

JANUARY 5, 1973, the Research 
Group of the Family Health Founda- 
tion released the second revision of a re- 
port entitled “Recent Trends in Louisiana 
Fertility.”^ A copy of this report was 
received by the Division of Tabulation and 
Analysis in March of this year shortly 
before the publication of “The Louisiana 
Family Planning Program; An Analysis 
of a Statistical Analysis.”^ We were sub- 
sequently informed by the Family Health 
Research Group that the January 5 eval- 
uation and the LFPP evaluation that we 
had critiqued in reference 3 were “in- 
house” reports prepared at the direction 
of federal officials for submission to a 
federal agency. The FHF research staff 
contended that such “in-house” reports 
were not part of “the literature” and, 
therefore, should not be subjected to the 
scrutiny and criticism of outsiders. When 
asked if such reports should not be subject 
to review because they were part of an 
effort to generate funding, the members 


* This is a shortened and annotated version of 
Part 2 of the “Report to the Medical Advisory 
Committee for Family Planning Services in Lou- 
isiana” prepared by the Division of Tabulation 
and Analysis, submitted to cited committee on 
November 28, 1973, and presented to the LHSRSA 
Board on December 5, 1973. 

Mr. Gettys is Head, Division of Tabulation and 
Analysis, LHSRSA. 

Ms. Atkins is Assistant Head, Division of Tabu- 
lation and Analysis. 

Dr. Mary is Commissioner of LHSRSA and 
State Health Officer. 


JAMES O. GETTYS, JR., MS 
E. H. ATKINS, MS 
CHARLES C. MARY, JR., MD 
New Orleans 

of the FHF Research Group remained 
unanimously steadfast in their original 
position. 

General Comments and Introduction 

Like most of the previous reports, the 
latest LFPP self-evaluation employs sev- 
eral standard LFPP techniques. For ex- 
ample, on page 7 of “Recent Trends in 
Louisiana Fertility,” we find a comparison 
of abbreviated age-parity grids (Louisi- 
ana nonwhite) for 1967 and 1971. As ex- 
pected, observed differences in these grids 
are reviewed on subsequent pages without 
mention of similar decreases which oc- 
curred before 1967. We omit details here 
because a lengthy critique of this same 
technique is given on pages 80 to 82 of 
reference 6. Similarly, to avoid redundan- 
cy, we will not comment here on several 
other sections of “Recent Trends in Lou- 
isiana Fertility.” But this new report is 
distinguished from other LFPP evalua- 
tions of demographic impact by several 
features: 

1) Louisiana crude birth rates are 
compared with those of the United States 
and Mississippi. 

2) Differences in age-specific non- 
white fertility rates in Louisiana between 
1965 and 1971 are compared with corre- 
sponding differences in Mississippi. 

3) The concepts of “parity compo- 
nents of age-specific rates” and “excess 
births” are introduced into the discussion 
of Louisiana fertility trends. 

We will devote most of this article to a 
discussion of these new procedures with 


March, 1974 — Vol. 126, No. 3 


81 


LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTYS, ET AL 


special emphasis on “parity components” 
and “excess births.” 

Comparison of Louisiana Crude Birth 

Rates with Those of Mississippi and 
the United States 

Table 1 of the January, 1973 report by 
FHF gives the number of live births per 
1,000 population in Louisiana and the 
United States for the years 1965-71 for 
both whites and nonwhites. In addition, 
the percentage of decline for the period 
1965-67 and 1967-71 is cited. To view 
these figures in the proper perspective, 
several important facts must be consid- 
ered: 1) Any comparison of Louisiana 
crude birth rates with those of the United 
States is questionable, since the racial and 
age composition of Louisiana’s population 
differs considerably from that of the na- 
tion as a whole (according to nationally 
prominent demographers; this fact alone 
renders comparisons of crude rates mean- 
ingless) 2) Family planning clinics 
did not exist on a statewide basis until 
approximately 1970, so that the percent- 
age of decrease in crude birth rate for the 
period 1964-1971 cannot be attributed to 
the LFPP alone; and 3) As of 1967, (make 
special note of this starting point) the 
year selected as a starting point for de- 
tecting the impact in Louisiana of the 
LFPP, clinics had been established in only 
seven parishes in the state and had been 
in operation in only six of these parishes 
(Lincoln Parish excluded) for an average 
of 41/2 months. It is, therefore, very ques- 
tionable that the percentage of decline in 
crude birth rate for both whites and non- 
whites in 1967 could be the direct result 
of the LFPP. Table 2 of the January, 
1973 FHF report gives the number of non- 
white live births per 1,000 population for 
Louisiana and Mississippi for the years 
1965-1971. Again, the percentage of 
change in crude birth rate for 1965-1967 
and for 1967-1971 is presented, and the 
decreases observed in Louisiana for the 
period 1967-1971 are attributed to the 
LFPP. It might be noted here that the 
two time periods for which percentage of 


change is calculated are not of the same 
length and, therefore, not strictly compa- 
rable, the first being two years in length 
and the second, four years in length. 

Differences in Age-specific Nonwhite 

Fertility Rates, 1965-71, for Louisiana 
and Mississippi 

In Fig 1 of the January, 1973 FHF re- 
port, the age-specific birth rates of the 
nonwhite populations of Louisiana and 
Mississippi are graphically represented 
for the years 1965 and 1971. The percent- 
age of change in birth rates for these years 
is also given. With respect to the latter 
figures, three main points should be con- 
sidered: 

1) Age-specific birth rates for Missis- 
sippi, especially for the latter years, were 
not obtained from the state itself but were 
estimated by the FHF. No mention was 
made of the method of estimation, nor 
were the actual values given for the num- 
bers of women in each age category. 

2) The years 1965-66 were included in 
calculating the percentage of change for 
the two states; thus the FHF was able to 
take advantage of the decrease in birth 
rate which occurred in all 64 parishes of 
Louisiana during those years, even though 
no LFPP clinics had been established in 
that time period (except the Lincoln Par- 
ish clinic which opened in September of 
1965). 

3) The selection here of the year 1965 
as a starting point for “detecting the im- 
pact” of LFPP on fertility in Louisiana 
represents a change in starting point of 
1967 used earlier in the same FHF report. 

Excess Births and Parity Components 

On page 8 of “Recent Trends in Louisi- 
ana Fertility,” we find the following defi- 
nition of “excess births,” which we are 
told is taken from pages 30 to 31 of “Pop- 
ulation Program Assistance” a publication 
of AID, Bureau of Technical Assistance, 
Washington, D.C.: 

A more detailed assessment of the impact of 
the program LFPP may be derived from an 
analysis of births by age and parity of mothers 
when the data are arranged in a grid. By defi- 


82 


J. Louisiana State M. Soc. 


LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTYS, ET AL 


nition that group of births born to mothers of 
parity 1-4 in the age group 20-39 are classified 
as “non-excess” ; births in the remainder of the 
grid are classified as “excess births.” The statis- 
tic, percent of births which are excess, may be 
employed as an index of program success. 

To illustrate this definition, we have in- 
cluded Table 1 which is the so-called “age- 
parity grid” for 1972 Louisiana nonwhite 
births. The shaded area in Table 1 shows 
the births which are classified as non- 
excess by the FHF definition. 

TABLE I 

AGE-PARITY GRID 



* Births to women under 15 and over 45 were 
excluded from this grid as were births for which 
parity and/ or age of mother was not known. 


Although the above definition of excess 
is employed in the FHF report, the statis- 
tic, percentage of births which are excess, 
was rejected by the Family Health Re- 
search Group for use as an index of pro- 
gi'am impact. 

The following explanations and new 
definitions are given beginning at the bot- 
tom of page 8 of the cited FHF repoid: 

In the analysis of current fertility trends in 
Louisiana, this technique shows the impact of the 
large component of young women entering the 
reproductive ages annually, causing an exaggera- 
tion in the percent of excess births. More than 
24.6 percent of all births in 1971 were 1 and 2 
parity births to women under 20 years of age. 
In order to compensate for this effect on the 
secular trends, each column of the age-parity grid 
was divided by the corresponding population. 
This converts the total number of births in each 
column to the age-specific birth rate. The entries 
in each row of a column are thus converted to 
parity components of the age-specific rates . . . 

Applying this new procedure to the age- 
parity grid in Table 1, we obtain the age- 
specific birth rates and parity components 


of those rates shown in Table 2. For the 
purpose of clarification, the 128.9 figure 
in the total row of the 15 to 19 column is 

TABLE 2 

PARITY COMPONENTS OF AGE-SPECIFIC 
BIRTH RATES* 

LOUISIANA NONWHITE. 1972 


Parity 

Age-Groops 


15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

1 

100.3 

66.6 

18.9 

5.3 

1.2 

0.1 

2 

23.8 

52.1 

28.8 

9.8 

2.5 

0-4 

3 

4.3 

28.6 

27.8 

12.0 

4.2 

0.6 

4 

0.6 

13.7 

23.1 

12.2 

4.5 

1.0 

5 

0.0 

5.1 

14.9 

11.3 

5.0 

1.3 

6 


1.5 

10.5 

9.6 

5.2 

1.6 

7 


0.4 

4.8 

7.8 

4.9 

1.4 

8+ 


0.1 

4.0 

13.3 

15.4 

6.9 

TOTAL 

128.9 

168.0 

132.8 

81.3 

42.9 

13.3 


* Population denominators used in calculating 
these rates and components were provided by the 
Research Division of Louisiana Tech University, 
College of Administration and Business. 

the 1972 age-specific birth rate for non- 
whites in the 15 to 19 age group; the 100.3 
figure in the parity 1 row of the same col- 
umn indicates that there were 100.3 first 
parity births to nonwhite women 15 to 19 
in 1972 per 1,000 nonwhite women in that 
age group. Note that the parity compo- 
nents of each age-specific birth rate sum 
to that rate (the sum of the components 
may differ from the rate by 0.1-0. 4 due to 
rounding errors) . Fig 1, copied from 
page 11 of “Recent Trends in Louisiana 
Fertility” shows how the Family Health 
statisticians used the concepts discussed 
above. This figure was given the follow- 
ing interpretation in the narrative of the 
cited report. (The italics are oui's.): 
Accepting for the moment the FHF 
excess/non-excess classifications of the 
age-parity components, we believe that 
Fig 1 does not really show the secular 
trends in the various measures discussed 
above. Fig 2 depicts the trends in the total 
excess component and in the component of 
excess associated with the 20 to 39 age 
group from 1962 through 1972. (Data for 
1972 were not available when “Recent 
Trends in Louisiana Fertility” was re- 
leased.) Considering the 11 years’ period 
of Fig 2, we can find no striking change 


O 


O 


March, 1974— Vol. 126, No. 


83 



LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTY S, ET AL 


FIGURE I 

SECULAR TREND OF AGE-PARITY COMPONENTS 
OF FERTILITY 

LOUISIANA, 1965-71, NONWHITE 



A graph of the secular trend of the sum of the 
age-specific fertility rates and its components in 
terms of excess and non-excess, from 1965 to 
1971 reveals some interesting differences (Fig 
1). The upper line shows the sum of the age- 
specific rates over all age groups. The remaining 
lines on the graph are a decomposition of the 
total by age-parity components. The summation 
line shows a break in the rate of reduction in 
1968. However, when the component parts are 
analyzed, it will be noted that the “non-excess” 
group declined at a slower rate up to 1968, then 
remained approximately stable to 1970 but took 
a turn upwards in 1971. Compensating, however, 
is the marked downward turn in the excess in 
the age groiip 20-39. It is among these women 
that the Louisiana Family Planning Program 
should have had its most marked effect. Further, 
in the age group 15-19, there has been little 
change in trend. 

whatsoever; the “marked downward turn” 
evidently began long ago. Since the Lou- 
isiana Family Planning Program has 
gradually spread over the state since 1965, 
not becoming a truly statewide program 
until 1970, it is difficult to decide when to 
expect impact. On the other hand, the Or- 
leans Parish program had a definite start- 


FIGURE 2 

SECULAR TRENDS IN THE COMPONENTS* OF EXCESS 
LOUISIANA, NONWHITE 



* The FHF definition of excess and calcula- 
tions of components used for this graph. 


ing point in late 1967, and consequently 
we can look for first impact on Orleans 
nonwhite fertility in 1969. Fig 3 shows 
the components of excess for Orleans Par- 
ish using the same FHF definitions and 
procedures that were applied to state data 
to obtain Fig 2. From Fig 3, we can glean 
two important facts: 1) The downward 
trend in the “total excess component” and 
the “component of excess in the 20 to 39 
age group” which began in 1964 deceler- 
ated for the first time in 1969; and 2) The 
“component of excess in the 15 to 19 age 
group” has risen every year since 1968. 


FIGURE 3 

SECULAR TRENDS IN THE COMPONENTS* OF EXCESS 
ORLEANS PARISH, NONWHITE 



* FHF Definition. 


To this point we have used the defini- 
tion of excess suggested by Family Health. 
However, we believe that this definition is 
an arbitrary one and perhaps not suited 
to the Louisiana Family Planning Pro- 
gram. It is true that until very recently 
LFPP could do little to avert or postpone 


84 


J. Louisiana State M. Soc. 


LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTYS, ET AL 


first parity illegitimate births; but accord- 
ing to LFPP literature, the reduction of 
second and higher parity illegitimate 
births is among the objectives of the pro- 
gram, and mothers whose last birth was 
out-of-wedlock are considered “high risk” 
by LFPP. Clearly then, for the purpose of 
an LFPP evaluation, all but first parity 
illegitimate births should be classified as 
excess. Moreover, since LFPP stresses 
child spacing, it seems a bit unreasonable 
to consider a third or fourth parity birth 
to a mother in the 20 to 24 age group as 
non-excess, especially if all births to 
mothers under 20 are in the excess cate- 
gory. In summary, we feel that the defi- 
nition of “excess” which is given by the 
non-shaded region in Table 3 is more ap- 
propriate to an evaluation of LFPPs im- 
pact on fertility than the AID definition 
used in “Recent Trends in Louisiana Fer- 
tility.” Fig 4 shows the secular trends in 
the Orleans Parish components of excess 

FIGURE 4 

SECULAR TRENDS IN THE NEW COMPONENTS* 

OF EXCESS 

ORLEANS PARISH, NONWHITE 



* Definition of excess given by non-shaded re- 
gion of Table 3. 


under the Table 3 definition of excess. 
Again several observations are in order: 
1) The trend in the “total excess compo- 
nent” and the “component of excess in the 
20 to 39 age group” shown in Fig 3 are 
even more “marked” under the new defi- 
nition of excess; and 2) At least, the “com- 
ponent of excess in the 15 to 19 age group” 
is stabilized after 1968. 


TABLE 3 

AGE-PARITY-STATUS GRID 



Toward the end of the LFPP report, 
the changes in the components of excess 
and non-excess betw^een 1970 and 1971 are 
discussed separately and in more detail 
than that given to the “secular” trends. 
On page 12 of “Recent Trends in Louisi- 
ana Fertility,” we find Table 4 accom- 
panied by the following: 

The above findings are further supported when 
the change from 1970 to 1971 is considered separ- 
ately. The change from 1970 to 1971 represents 
the time period for which program impact should 
be greatest in terms of active contraceptors in 
the population. It is clear that excess births 
have decreased in all groups except for parity 1 
births in the 15 to 19 age group. In the non- 
excess group the principal change was an in- 
crease in parity 1-2 births in the 20-29 group. 

TABLE 4 

CHANGE IN PARITY COMPONENTS OF 
AGE-SPECIFIC BIRTH RATES 
FROM 1970 TO 1971 
LOUISIANA. NONWHITE 


PARITY 

AGE GROUP 

15-19 

20-24 25-29 

30-34 35-39 

40-44 

1 

2 

3 

4 

5 

6 
7 

8-f- 

+ 7.2 

1-20.0 

+ 5.8 

-2.0 

-6.9 

-2.9 

+- 7.2 

-52.8 


A. Non-excess (20-39 age group parity 1-4). 
In this group the total increase in the rate was 
30.1 parity units. Of this increase 66% (20.0 
units) was in parity 1-2 births among women 
20-29 years of age. 

B. Excess 

1. 15-19 years old. In this group the total 


March, 1974 — Vol. 126, No. 3 


85 


LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTYS, ET AL 


rate increase was 0.3 parity units. This resulted 
from an increase of 7.2 units at parity 1 and a 
decrease of 6.9 units at higher parities, 

2. 20-39 age group parity 5-f. In this age 
parity group the rate decreased by 52.8 parity 
units. 

3, 40-44 age group. A decrease of 2.0 units 
occurred in the rate for this age group. 

TABLE 5 

CHANGES IN AGE-PARITY COMPONENTS OF 
AGE-SPECIFIC BIRTH RATES 
ORLEANS PARISH. NONWHITE 



AFTER LFPP: 1970 - 1971 



Although never said, it is at least im- 
plied that the changes from 1970 to 1971 
were unique. This is simply not so; sim- 
ilar and even more impressive changes can 
be demonstrated at the state level between 
almost any pair of consecutive years from 
1964 to 1968. However, because of prob- 
lems associated with determining a start- 
ing point for the state program, we will 
limit our demonstration to Orleans Parish. 
Table 5 shows the changes (corresponding 
to the LFPP definition of excess) in Or- 
leans Parish components of nonwhite fer- 
tility rates for 1966-1967 and 1970-1971. 
Table 5 speaks for itself. 

We have added Table 6 to avoid the pit- 
falls of large grouping and to better con- 
form with the definition of excess that we 
proposed earlier. The shaded area in the 


lower part of Table 6 marks those cells of 
the “after” grid in which the change 
tends to the “desired” as much or more 
than the change in the corresponding cell 
of the “before” grid. Table 6 tells basical- 
ly the same tale as Table 5 but in more 
detail. 

TABLE 6 

DETAILED CHANGES IN AGE-PARITY-STATUS 
COMPONENTS OF AGE SPECIFIC BIRTH RATES. 

ORLEANS PARISH. NONWHITE 


BEFORE LFPP: 1966 • 1967 

I I 


3 i 




AGE G 

ROUP 



gg 

3 wj 

< 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 


1 

-3.5 

-2.5 

-0.2 

-0.5 

-0.3 

-0.2 


2 

-1.8 

-3.2 

-K).l 

-2.2 

-1-1.8 

-FO.l 

3 

3 

-1-1.0 

-8.0 

-1-2.7 

-3.9 

-2.0 

+0.2 

g 

4 

-0.7 

-9.7 

-1.6 

-K).3 

-0.8 

+0.7 


5-1- 

-0.3 

-10.9 

-11.6 

-5.9 

-9.3 

+1.7 


1 

-1-1.3 

-1-3.3 

-K).3 

-1.6 

0 

0 

O 

2 

-1-1.0 

-1.5 

-1.7 

-0.7 

-0.5 

-0. 1 


3 

-fO.7 

-1-1.7 

-fO.6 

-1.7 

-1.1 

0 

t 

4 

-K).3 

-FO.l 

-1.1 

-0.4 

-K).4 

0 

3 

5-1- 

-0.4 

-1.5 

-1.7 

-1.9 

-0.8 

-0.5 

TOTAL 

-2.5 

-29,2 

-13.9 

-18.3 

-12.8 

+2.1 


AFTER IFPP: 1970 - 1971 

S T— 




§ e 

e 

AGE GROUP 

gs 

3 v> 

s 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 


1 

+1.2 

+3.2 

+5.4 

+2.9 

+1.0 

+0.2 


2 

+1.5 

+5.1 

+3.6 

+2.7 

0 

+0.9 

k 

3 

-0.9 

-0. 1 

+4.5 

+1.4 

+0.7 

-0.2 

3 

Z 

4 

-O.l 

-3.6 

+1.3 

+3.3 

+1.7 

0 


5+ 

+0.2 

-3.3 

-It. 5 

-6.9 

-0.4 

+0.7 



+0.4 

+4.5 

-0.1 

+0,7 

+0.4 

-0.4 



-«>.8 

+3.8 

+2.0 

+0.6 

+0.5 

0 

S 


+0.1 

+1.4 

+1.9 

-0.1 

+0.4 

-O.i 

t 

4 

-0.2 

+0.8 

40,6 

+0.5 

+0.4 

+0.3 

° 

5+ 

0 

-1.4 

^ 1,7 

-1.1 

+1.1 

+0.2 

TOTAL 

+10.9 

+10.4 

+4.7 

+4.0 

+5.6 

+1.7 


The FHF Summary of Recent Trends 

The last paragraph of “Recent Trends 
in Louisiana Fertility,” which we have du- 
plicated below, is the most interesting part 
of the report. Again we have added italics. 

In summary, the fa.mily planning activities of 
the Family Health Foundation in Louisiana have 
had a very significant impact on fertility in the 
state. (1) In the last four years the rate of 
decrease in fertility levels has been more than 
twice that for the nation, despite the fact that 
the program has reached only an insignificant 
proportion of the white population. In the non- 
white population, the decrease has been more 
than twice that of the white population. (2) In 
Louisiana, since 1967, the non-white birth rate 
decreased by 10.0 percent; in the neighboring 


86 


J. Louisiana State M. Soc. 


LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTYS, ET AL 


state of Mississippi, which has not had a state- 
wide family planning program, the comparable 
rate has increased by 2.5 percent. (3) Although 
the number of nonwhite females under 25 years 
of age has shown a marked increase since 1967, 
the total number of births has decreased. The de- 
creases have occurred at parities 3-|- at ages 20 
and above and at parities 2-(- in the 15 to 19 year 
olds. This is in accord with the expected outcome 
for a program directed primarily toward ever- 
married, ever-pregnant women. The most notable 
increase in births from 1967 to 1971 was in out- 
of-wedlock births to 15 to 19 year old women. 
With a 1972 change in statutory constraints on 
provision of services to unmarried teenagers it is 
reasonable to expect significant reductions in out- 
of-wedlock parity one births. {U) Except for par- 
ity one births to teenagers, components of the 
excess birth rate have decreased in all age groups. 
Components of the non-excess birth rate (parity 
1-4 in the 20 to 39 year age group) have shown 
recent increases but these have been principally 
confined to parity 1-2 births among 20 to 29 year 
old women. 

This quotation clearly shows that FHF 
has stopped suggesting and implying; it 
has begun to boldly claim “significant” 
program impact on the vital forces of the 
state. In fact, what the term “significant” 
is supposed to mean in FHF reports is not 
clear. It should be noted that FHF has 
not reported the results of any valid statis- 
tical test of significance of any changes in 
Louisiana fertility, but has limited itself 
to presentations of raw data in tabular or 
graphical form. 

Summary 

Although we have been misquoted many 
times as saying that LFPP has had no 
impact on fertility in Louisiana, we have 
never made such a claim. Our position on 
the demographic impact (or lack of demo- 
graphic impact) of LFPP can be stated as 
follows: 

1) No scientific or even pseudoscien- 
tific analysis of the program’s impact has 
ever been published or made available by 
FHF to any state agency. If no valid 
analysis of impact/nonimpact has ever 
been performed, it seems fair to ask why, 
since the FHF’s Research Group is more 
than capable of performing such an anal- 
ysis. If such an analysis has been per- 
formed and withheld from “outsiders,” 


there is an even stronger reason for posing 
questions. 

2) The so-called evaluations of the de- 
mographic impact of LFPP are in fact 
textbook examples of customized statis- 
tics. This language may seem strong, but 
it is really polite compared with phrases 
used by some prominent physicians, de- 
mographers, university professors, popu- 
lation experts, etc. A quite common phrase 
used by others to describe the FHF re- 
ports is “academic fraud.” 

3) As Polgar and Kessler pointed out 
in 1968, “Little attention has been given 
to date to the actual or potential impact of 
family planning services on increasing 
natality.”” The same article goes on to say 
that higher population growth “would be 
a consequence of two different factors: 
first the provisions of treatment for in- 
fertility problems and second the improve- 
ment of survival rates.” In his 1972 ar- 
ticle,” Reynolds suggests a third factor 
associated with family planning programs 
that may contribute to increased natality: 

. . . poor family planning services. It is our 
personal impression, says Reynolds, that poorly 
organized and administered family planning ser- 
vices contribute to the increase of unwanted fer- 
tility. It is an entirely plausible hypothesis that 
poor education on how to use contraceptives 
coupled with intermittent service and irregular 
provision of contraceptive supplies could result 
in unwanted pregnancies. 

We see the possible increases described 
by Polgar as positive results of a family 
planning program. However, in the light 
of recent disclosures concerning FHF 
“home visits,” we must at least consider 
the possibility that the type of increase ex- 
plained by Reynolds has been experienced 
in Louisiana. 

One final and important note is in order 
concerning the Family Health Research 
Group. As Reynolds puts it: 

. . . the assumption is that FPP workers are 
highly motivated to bring down the birth rate, 
whereas it is more likely that they are highly 
motivated to retain their jobs, regardless of what 
happens to the birth rate.-’ 

Moreover, we are not convinced that 
the highly respected statisticians on the 
FHF staff are even responsible for all of 


March, 1974— Vol. 126, No. 3 


87 


LA. FAMILY PLANNING PROGRAM’S IMPACT— GETTYS, ET AL 


the narrative that has accompanied their 
charts and tables. 

Acknowledgements 

We gratefully acknowledge the assis- 
tance of the entire staff of Tabulation and 
Analysis of LHSRSA, Division of Health 
Maintenance and Ambulatory Patient Ser- 
vices, in the preparation of this paper, 
especially Mrs. Audrey P. Collins, Mrs. 
Beatrice Bonin, Mrs. Patricia Simon, and 
Mr. Albert Frommeyer. Special thanks 
are also due several faculty members of 
the Tulane University School of Public 
Health and Tropical Medicine who lent 
their technical advice and/or expertise to 
this project. 

References 

1. Recent Trends in Louisiana Fertility, 2nd Revision. 
The Family Health Foundation Research Group, January 
5, 1973 


2. Statistical Analysis of the Louisiana Family Plan- 
ning Program. 1967-1971. Family Health Research Group 
Publication #1, December 2, 1971 

3. Gettys JO. Fz'eedman B, Vidrine RK : The Louisiana 
Family Planning Program: An Analysis of a Statistical 
Analysis. J Louisiana State Med Soc, vol. 125, No. 3 
(March) 1973 

4. Gettys JO, Collins AP : Trends in Mortality for 

Louisiana and Her Parishes. Statistical Report of the 
Bureau of Vital Statistics, 1972. LHSRSA, Division of 
Health Maintenance and Ambulatory Patient Services 

5. Gettys JO, Collins A: Some Common Misinterpre- 
tations of Louisiana Mortality Statistics. LHSRSA Public 
Health Statistics, 1973 Series, No. 1 

6. Dickinson FG, Welker EL: What is the Leading 

Cause of Death? Two New Measures. AMA 1948, Bul- 
letin 64 

7. Haenszel W : A Standardized Rate for Mortality 

Defined in Units of Lost Years of Life. AJPH (Jan) 
1950 

8. Brockert John E: Use of Vital Statistics Data for 
Determining Program Priorities. Presented at the 1973 
Annual Meeting of the American Association for Vital 
Records and Public Health Statistics 

9. Reynolds J : Evaluation of Family Planning Pro- 

gram Performance : A Critical Review. Demography, vol. 
9. No. 1 (Feb) 1972 


88 


J. Louisiana State M. Soc. 


Proficiency Testing in the Physician’s 
Office Laboratory: An Ounce of Prevention* 

• This Is an Interesting report about the importance of proficiency 
testing of laboratory values carried out In the physician's own lab- 
oratory. All physicians in practice will benefit from a review of this 
paper. 

RAYMOND F. MAIN, MDf 
Oklahoma City, Okla. 


T APPRECIATE this opportunity to 
bring you a message, the implications 
of which may have a considerable impact 
on your office practice. I speak as a 
friendly s\Tnpathetic colleague and plead 
with you to interpret my remarks in that 
context. 

It has been alleged to the Congress of 
these United States that the poorest of all 
laboratory work is that done in the private 
physician’s office.^ If for no other reason 
than convenience, physicians are going to 
continue to do laboratory work in their 
own offices. However, the impact of such 
testimony means that standards now ap- 
plied to independent and hospital labora- 
tories will eventually be applied to the 
physician’s office laboratory. Judging 
from the comments at a National Profi- 
ciency Testing Conference, October 4-6, 
1971 at the National Center for Disease 
Control in Atlanta, that eventuality may 
be much closer than we think. Two states, 
California and Arizona, have already 
passed legislation requiring physicians’ of- 
fice laboratories to participate in profi- 
ciency testing beginning January 1, 1972. 
For me, a pathologist, to argue that phy- 
sicians should not do laboratory work in 
their own office is the epitome of naivete. 
For you, a private physician, to argue that 
you do not need standards for laboratory 


* Read before the Section on Pediatrics, South- 
ern Medical Association, Sixty-fifth Annual Meet- 
ing, IMiami Beach, Fla, Nov. 1-4, 1971. 

t From the Medical Arts Laboratory, Pasteur 
Building, Oklahoma City, Okla. 

Published ^rtth permission of the Southern 
Medical Journal. This appeared in vol 65:609-610 
(May) 1972. 


work done in your own office is an unwit- 
ting disservice to the patients you serve. 
We would both have our heads buried in 
the sands of unreality; an awkward and 
dangerous posture. Instead, my posture 
should be, “What can I do to help you 
assure that you are doing reliable labora- 
tory work?” Your posture should be, 
“What do I need to do to be certain that 
the laboratory information generated in 
my office is medically useful?” Some of 
you may choose to disregard the implica- 
tions of these statements, and others may 
challenge their validity. Before you do so, 
however, let us look at some facts. 

In 1968, the Oklahoma State Medical 
Association (OSMA) created a Labora- 
tory Quality Committee to address itself 
to the physician’s office laboratory. The 
committee’s first step was to invite phy- 
sicians doing office laboratory work to 
participate in a voluntary proficiency test- 
ing program made available by the Col- 
lege of American Pathologists. The pur- 
pose of this progi'am was two-fold. One, 
to ascertain the magnitude of the alleged 
problem, and two and more importantly, 
to use the information obtained to plan 
educational progi'ams to correct deficien- 
cies that might become apparent. 

In 1969, 24 physicians’ office labora- 
tories participated in this program; in 
1970, 81 participated. A summaiy of the 
results is shown in Table 1. 

Let me clarify the distinction between 
technically unacceptable results and med- 
ically misleading results. For example, if 
a urea nitrogen proficiency test sample has 
a mean value of 16 mg percent with a 
standard deviation of 1.0 mg percent, the 


March, 1974 — Vol. 126, No. 3 


89 


PROFICIENCY TESTING IN THE PHYSICIAN’S OFFICE LABORATORY— H AIN 


TABLE I 

SUMMARY OF 1969 AND 1970 OSMA 
PHYSICIAN'S OFFICE LABORATORY PROFICIENCY 
TEST RESULTS 


-S 


Year 

No. of 
Participant! 

No. 

Reported 

Values 

>* ^ 

V Q. 
u o 

I « 

■o 2 
(%) 

— ^ Medically 
L. Misleading 

1969* 

24 

1176 

12.7 

5.7 

1970f 

70 

3786 

10.0 

5.8 

1970* 

10 

517 

10.0 

7.0 

1970J 

1 

92 

21.0 

18.0 


* College of American Pathologists Basic Sur- 
vey Series. 

t College of American Pathologists PEP Series. 

J College of American Pathologists Comprehen- 
sive Chemistry Series. 

technically acceptable range would be 14 
to 18 mg percent. If a participant report- 
ed a value of 13 mg percent, this would 
be technically unacceptable. It would not, 
however, be medically misleading. If, on 
the other hand, the reported value was 35 
mg percent, this would not only be tech- 
nically unacceptable, but it would also be 
medically misleading as it would mislead 
the physician in the care and treatment of 
his patient. The limits for medically mis- 
leading values were established by the clin- 
icians on the OSMA Laboratory Quality 
Committee. 

These overall results are surprisingly 
good, especially when viewed in the con- 
text of the allegations and of published 
reports citing the performance of labora- 
tories other than in the physican’s office. 
For example, a survey of 6,000 tests done 
in 170 Canadian laboratories revealed 47 
percent of the reported results were out- 
side the limits of acceptable error, and 22 
percent of these were 5 times greater than 
the allowable limits of error.^ A survey of 
hemoglobin determinations in 398 labora- 
tories throughout the United States re- 
vealed 33 percent were technically unac- 
ceptable.^ Closer to home let us look at 
the results of surveys of a group of Okla- 
homa rural hospitals conducted in 1966 
and 1969 (Table 2). The figures, I believe 


speak for themselves. Compared with 
1966, the 1969 perfonnance is a most dra- 
matic improvement, and I am happy to 
report that a review of results in a June, 
1971 proficiency testing survey shows es- 
sentially the same high level of perfor- 
mance. This improvement in performance 
did not “just happen,” nor is it the result 
of proficiency testing alone. It is the 
result of a supervised daily quality control 
program and a continuous educational pro- 
gram in which proficiency testing is used 
to monitor their effectiveness and to iden- 
tify specific additional educational needs. 
While the overall results from the physi- 
cians’ office laboratories are better than 
experts predicted, there are some thorns 
among the roses. The performance of 
OSMA participants for selected proce- 
dures in the survey is shown in Table 3. 
I think you will agree there is room for 
improvement. 


TABLE 2 

PROFICIENCY TEST PERFORMANCE OF SMALL 
RURAL HOSPITALS IN OKLAHOMA 


Test 

Material 


1966 



1969 


No. Values 
Reported* 

~ Technically 
~ Unacceptable 

^ Medically 
Misleading 

No. Values 
Reported! 

~ Technically 
~ Unacceptable 

.E 

U <0 
« 

2 2 
{%) 

Hemoglobin 

48 

59 

25 

326 

5 

0.3 

Urea nitrogen 44 

57 

25 

318 

4 

0.7 

Glucose 

47 

13 

2 

328 

6 

1 

Uric acid 

43 

12 

5 

270 

5 

2 

Calcium 

25 

36 

24 

150 

7 

2 

Bilirubin 

37 

19 

11 

276 

6 

0.7 

Cholesterol 

47 

11 

11 

280 

8 

2 

Bacteriology! 75 

57 

57 

77 

24 

18 


* Each value represents a different hospital, 
t Composite of 3 check samples each with 2 
concentrations. 


t Two check samples — each a different or- 
ganism. 

Ideally we should strive for no medically 
misleading values. Human that we are 
probably precludes this. Therefore, we 
need to reach the irreducible minimums 
which in all probability can be at the one 
percent level or less. Note the discrepancy 
between the percentage of technically un- 


90 


J. Louisiana State M. Soc. 


PROFICIENCY TESTING IN THE PHYSICIAN’S OFFICE LABORATORY— H AIN 


TABLE 3 

SELECTED CONSTITUENT RESULTS OF 
OSMA PARTICIPANTS 


Constituent 

Technically 

Unacceptable 

Medically 

Misleading 

1969 

(%) 

1970 

(%) 

1969 

(%) 

1970 

(%) 

Glucose 

21 

17 

6.7 

9.8 

Bilirubin 

24 

9 

1.6 

3.3 

Cholesterol 

17 

4 

1.8 

2.1 

Urea nitrogen 

18 

19 

3.2 

8.2 

Uric acid 

23 

16 

10.5 

10.6 

Hemoglobin 

18 

8 

2.2 

2.1 


acceptable and medically misleading values 
in 1969 and 1970. If you look at the dif- 
ferences in the percent of technically unac- 
ceptable results, it would appear that the 
1970 performance is better. If, on the 
other hand, you look at the percent of 
medically misleading values, the 1970 per- 
formance is poorer. This apparent para- 
dox is due to the fact that the limits for 
technical acceptability were wider in 1970 
than in 1969 because of the difference in 
the composition of the peer groups whose 
performance was used to establish these 
limits, whereas, the medically misleading 
limits set by the clinicians were essentially 
the same in both years. 

When one analyzes the survey data on 
the basis of performance of the individual 
physician’s office laboratory, the rosebush 
is even thornier (Table 4). Seventy-nine 
percent of the participants reported one or 
more medically misleading values, and 23 
percent reported more than 10 percent 
medically misleading values with the poor- 
est being 30 percent. It is of interest that 
of the 16 physicians’ office laboratories 
reporting more than 10 percent medically 
misleading values, 10 were using the Bio- 
Dynamics Unimeter Instrument and 5 a 
precalibrated Leitz Colorimeter which had 
not been recalibrated since the day it was 
purchased. This does not necessarily mean 
that the instruments were at fault. It does 
mean, however, that under the circum- 
stances in which they were used they did 
not produce reliable laboratory informa- 
tion. 


TABLE 4 


INCIDENCE OF MEDICALLY MISLEADING VALUES 
REPORTED BY INDIVIDUAL OSMA PARTICIPANTS 
IN 1970 PROFICIENCY TESTING PROGRAM 

Medically 


Misleading 


Values 

Percent of 

(%) 

Participants 

0 

21 

1- 5 

36 

6-10 

20 

11-15 

6 

16-20 

11 

over 20 

6 


This prompts me to emphasize that pro- 
ficiency testing is a valuable tool to alert 
you to problems in your laboratory, but it 
does not correct them. Nor should it be 
used as a substitute for a total quality con- 
trol program. The latter must be a daily 
surveillance program with proficiency 
testing used to periodically monitor its ef- 
fectiveness. That a supervised daily qual- 
ity control program does have a favorable 
impact on performance was seen in the 
improvement in performance of the small 
hospitals. Table 5 illustrates its impact on 
performance in the physician’s office lab- 
oratory. Note the performance of the 10 
physicians’ office laboratories on the last 
line. 

TABLE 5 

SUMMARY OF 1969 AND 1970 OSMA 
PHYSICIAN'S OFFICE LABORATORY PROFICIENCY 



TEST 

RESULTS 



Year 

No. of 
Participants 

No. 

Reported 

Values 

— ^ Technically 
^ Unacceptable 

. — ■ Medically 
Misleading 

1969* 

24 

1176 

12.7 

5.7 

1970f 

70 

3786 

10.0 

5.8 

1970* 

10 

517 

10.0 

7.0 

1970f 

10$ 

678 

3.0 

1.3 


* College of American Pathologists Basic Sur- 
vey Series. 

t College of American Pathologists PEP Series. 
t Participating in a Supervised Quality Control 
Program. 

Even more impressive is an analysis of 
the June, 1971 proficiency test results of 


March, 1974 — Vol. 126, No. 3 


91 


PROFICIENCY TESTING IN THE PHYSICIAN’S OFFICE LABORATORY— HAIN 


21 physicians’ office laboratories partici- 
pating in this same supervised quality con- 
trol program (Table 6). Of 208 reported 
values, only 2, less than 1 percent, were 
medically misleading. Furthermore, both 
of the medically misleading values were 

TABLE 6 

PROFICIENCY TEST RESULTS* OF 21 OSMA 
PHYSICIANS' OFFICE LABORATORIES ON 
SUPERVISED QUALITY CONTROL PROGRAM 


Constituent 

No, Values 

Technically 

Unacceptable 

(%) 

Medically 

Misleading 

(%) 

Glucose 

42 

7 

0 

Bilirubin 

22 

9 

0 

Cholesterol 

40 

5 

0 

Urea nitrogen 

34 

6 

6 

Uric acid 

28 

0 

0 

Hemoglobin 

42 

17 

0 

Total 

208 

8 

< 1 


* June 1971 College of American Pathologists 
PEP Survey. 


reported by the same laboratory, thus 20 
of 21 participants, or 95 percent, reported 
no medically misleading values. 

I think you will agree that there is some 
merit in taking a closer look at the relia- 
bility of laboratory information generated 
in your office. Voluntary participation in 
a proficiency testing program is a good 
start. I urge those of you not already 
doing so to participate in the College of 
American Pathologists Physicians Office 
Laboratory Evaluating Programs. It could 
be the ounce of prevention that prevents 
the mandatory pound of cure. The decision 
is yours. 

References 

1. Schaeffer M: Director, Bureau of Laboratories, 

New York City Department of Health, New York. State- 
ment to Senate Committee of the Judiciary Committee on 
Antitrust and Monopoly, February 7, 1967 

2. Tonks D: A study of the accuracy and precision 

of clinical chemistry determinations in 170 Canadian lab- 
oratories. Clin Chem 9:217-233, 1963 

3. Sunderman FW : Status of clinical hemoglobinom- 

etry in the United States. Amer J Clin Path 43 :9-16, 1966 




92 


J. Louisiana State M. Soc. 



ledical Grand Rounds 

from 

Touro Infirmary 


Diabetes and Neuropathy 


Edited by SYDNEY JACOBS, MD 
New Orleans 


Dr. Jacobo Vestel A 53-year-old 
Negro, gravida XI, Para 10, was admit- 
ted to the hospital because of nausea, 
vomiting and abdominal pain occurring 
seven weeks after the appearance of a 
perianal abscess had led to the detec- 
tion of diabetes mellitus and hyperten- 
sion (blood pressure 180/100). Several 
members of her family had diabetes and 
hypertension, and one of her daughters 
had weighed nine pounds at birth. When 
the perianal abscess was found, neither 
neuropathy nor retinopathy was de- 
tected. The patient stayed at Touro 11 
days, became normotensive and asymp- 
tomatic and was discharged with dietary 


instructions and a prescription for Dia- 
binese. 

The morning of the current admission 
she woke up vomiting and complaining 
of right upper quadrant colicky pain as 
a result of which she was admitted to 
the hospital. The admission diagnoses 
were acute cholecystitis, diabetes mel- 
litus of adult onset with mild keto- 
acidosis. The ECG was suggestive of 
left ventricular hypertrophy. The chest 
x-ray was normal, and a film of the 
abdomen showed no evidence of disease. 
The patient was treated with insulin and 
parenteral fluids. During the first 24 
hours in the hospital, the abdominal 
symptoms were relieved ; on the second 
day, a sudden onset of marked ptosis 
and external ophthalmoplegia of the 


Intern, Touro Infirmary. 

March, 1974— Vol. 126, No. 3 


93 


MEDICAL GRAND ROUNDS — Touro Infirmary 


A powerful lot of people 
have been saving at 
Eureka since 1 884 



2525 Canal Street Phone 822-0650 
110 Belle Chasse Hwy. 

West Bank Division 
EUREKA HOMESTEAD SOCIETY 


right eye were noticed. Only lateral 
movements of the eye were preserved. 
The pupillary reflexes were normal. The 
remaining cranial nerves, including the 
3rd, 4th and 5th in the left side, were 
intact. There was no diplopia, no visual 
deficit, and funduscopic studies were 
unremarkable bilaterally. The patient 
was alert, well-oriented and cooperative. 
Voluntary motility was conserved. There 
was no weakness or abnormal reflex. 

Protopathic and epicritic discrimina- 
tions were normal as were coordina- 
tion and equilibrium. An ophthalmolo- 
gist and a neurologist were called in 
consultation, and both supported the 
clinical diagnosis of right 3rd nerve 
palsy, ischemic in origin and probably 
due to vascular changes secondary to 
diabetes mellitus. During the following 
week, another cholecystogram showed 
a probably normal gallbladder while 
gastrointestinal series revealed a small 
hiatal hernia. The skull x-rays and the 
brain scan were normal. The patient 
was placed on a 1500 calorie diet with- 
out insulin. The fasting blood sugar 
decreased to 150 mg, and she was dis- 
charged without any symptoms. The 
discharge diagnoses were : cholecystitis ; 
and diabetes mellitus with diabetic 
neuropathy of the 3rd nerve. 

Dr. Juan Ordonez The GI symp- 
toms were rather mild and nonspecific 
enough so that most common abdominal 
diseases had to be considered. After 
diagnostic studies, we came to accept 
mild, subsiding cholecystitis as the cause 
of her distress and as an acute infectious 
process leading to ketoacidosis at which 
stage her “adult onset” diabetes mellitus 
was detected. Inasmuch as none of us 
found any evidences of retinopathy, of 
peripheral vascular disease or of der- 
mopathy, we were surprised by the 
onset of external ophthalmoplegia. We 
know, of course, that neural changes in 
diabetes have very little established 

(b) First year medicine resident, Touro Infir- 
mary. 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS— Touro Infirmary 


relationship to the metabolic status, at 
times appearing even before overt car- 
bohydrate intolerance. Because neurop- 
athies are so common in diabetics and 
because the short clinical evolution of 
the syndrome did not suggest any other 
etiology, our final diagnosis was diabetic 
neuropathy. In general, diabetic neurop- 
athy is regarded as being either sensory 
and bilateral or motor and unilateral. 
Whether this neuropathy is ischemic or 
metabolic in origin is still being debated. 

Miss Patricia Roig:<*^^ This patient 
did not seem to have any problems. She 
talked mainly about her family and her 
children, some of whom would visit her 
quite often. She had no financial diffi- 
culties. Her husband has been working 
at the same company for a while. 

Miss Patricia Caldwell: She had 
been obese for some time and still is 
about 30 pounds overweight for her 
age and height. She went on a diet 
when the diabetes was diagnosed and 
has only lost 51/2 pounds, which really 
is not much of a weight loss. 

Dr. Sydney Jacobs: She is 53 years 

old. She has diabetes in heredity, and 
yet she “waits” until she is 53 years old 
before she shows up with diabetes. She 
has been pregnant 11 times; so she 
almost certainly did not exhibit diabetes 
early in life. Priscilla White often 
noted that before the days of insulin 
it was a rare thing to see a diabetic 
child mature and give birth to a live 
baby. The effect of age on the expres- 
sion of the diabetic genotype is well 
illustrated here. Everyone accepts dia- 
betes as a disease with strong genetic 
implications; but there is no agreement 
on just how the hereditary influences 
are made manifest. In identical twins, 
for example, concordance for diabetes 


Clinical counselor, Touro Mental Health 
Center. 

Staff dietitian, Touro Infirmary. 

Chief, Department of Medicine, Touro In- 
firmary; Clinical professor of medicine, Tulane 
University School of Medicine. 


exists in 65 percent, whereas it exists 
in only 22 percent of fraternal twins; 
yet if one studies only fraternal twins 
who are 43 years or older, concordance 
reaches almost 100 percent. It has been 
suggested that a certain serum com- 
ponent (“synalbumin”) is an insulin 
antagonist, and that maturity-onset dia- 
betes is the result of the heterozygous 
state for the gene controlling synal- 
bumin, whereas juvenile diabetes is the 
result of a comparable homozygous 
state. Whatever our patient’s inheri- 
tance of diabetogenic factors, she didn’t 
present with recognizable diabetes until 
after she had borne 11 children, waxed 
fat, reached the age of 53 years and 
had sustained a serious infection. Possi- 
bly her diabetic genotype might have 
escaped phenotypic expression without 
these modifying factors. 

Dr. Ruth D. Paterson: I quite 

often see patients with polyneuropathy 
in middle age, and the first diagnosis 
I think of is diabetes. In patients with 
late onset diabetes which is often mild 
and uncomplicated by ketoacidosis, the 
presentation with neuropathy is not in- 
frequent. I believe that in this patient 
the prognosis is excellent. I told her I 
thought she would recover from the 
ocular paralysis in about six to eight 
weeks. This differs from the more typi- 
cal, symmetrical, distal predominantly 
sensory polyneuropathy of diabetes. We 
don’t know why diabetics get this sec- 
ond, more common type of neuropathy; 
presumably, it is due to a disturbance 
in carbohydrate metabolism, and it is, 
of course more insidious in onset and 
lasts much longer, even with good dia- 
betic control, which we always say is 
essential in treatment. It resolves very 
slowly. The mononeuropathies of dia- 
betes, on the other hand, present acutely 
and usually with pain. If it is a cranial 
neuropathy, often it comes on with mod- 
erate pain retro-orbitally if it is in the 


Professor of medicine and psychiatry and 
neurology, Tulane University School of Medicine. 


March, 1974— Vol. 126, No. 3 


95 


MEDICAL GRAND ROUNDS — Touro Infirmary 


3rd nei’ve. The pain lasts a few days 
and subsides; the neuropathy and signs 
of weakness persist for about two 
months. Then they improve, and the 
patient makes a complete recovery. This 
is probably an ischemic neuropathy ; and 
the acute onset with pain and the com- 
plete recovery are consistent with this 
etiology. The reason that there have 
not been many pathological studies is 
that all patients recover; and so it is 
only by chance that two or three patho- 
logical studies were reported. Years ago, 
Raymond Adams found some ischemic 
changes in the cavernous portion of the 
3rd nerve of a patient who had died fol- 
lowing carotid angiography for a sus- 
pected carotid aneurysm. We had to 
differentiate here between a 3rd nerve 
palsy due to diabetes and an internal 
carotid aneurysm. Remembering that 
the pupillary fibers on the peripheral 
part of the nerve are compressed early 
by aneurysm and should cause the pu- 
pil to dilate (but this patient’s pupils 
were normal in size and in their reac- 
tions), we concluded that diabetes was 
a more likely cause than an aneurysm 
for the ophthalmoplegia. 

Dr. Melvyn Kossover:^°^ When she had 
the abscess of the buttock, there was 
absolutely no abnormal neurological 
finding. The symptoms which brought 
her to the hospital the second time did 
include headache, dizziness and abdom- 
inal pains, so that the neuropathy could 
have started at that time. 

Dr. Carlos Alfaro: In your experi- 
ence, have you found any correlation 
between retinal changes and neurop- 
athy? 

Dr. Paterson: Middle-aged diabetics 
often do have narrowing of the retinal 
arterioles; but I don’t think it is always 
present when they have a neuropathy 
of this kind. In fact, many people be- 


(8) Clinical assistant professor of medicine, Tu- 
lane University School of Medicine. 

(h) First year medicine resident, Touro Infir- 
mary. 


lieve that occlusive arterial disease in 
diabetes does not completely explain the 
occurrence of diabetic ischemic neurop- 
athy. A disturbance of oxidative me- 
tabolism may explain the fact that these 
neuropathies are more common in dia- 
betics than they are in other patients of 
similar age with arteriosclerotic disease 
or peripheral vascular disease. 

Dr. Kossover: Do so-called peripheral 
vasodilating drugs have any beneficial 
effects ? 

Dr. Paterson: No. The cerebral ar- 
teries are not dilated by any of the drugs 
used to cause dilatation of the peripheral 
arteries. The cerebral blood flow is very 
resistant to change either physiological- 
ly or pharmacologically. 

Dr. Jacobs: Dr. Ordonez, do you think 
the patient understands the significance 
of her diabetes? 

Dr. Ordonez: No, I don’t think so. Al- 
though we talked to her, I don’t think 
she understands the problems of adult 
onset diabetes and why it is so easily 
controlled. It is probably very impor- 
tant for someone having diabetes to have 
a detailed understanding of her disease; 
however, that understanding depends on 
the mental capacity and education. 

Miss Roig: She said she completed 
the 9th grade, so she should be able to 
understand and follow a diet. 

Dr. Jacobs: Yet, she came back to the 
hospital in diabetic ketoacidosis the sec- 
ond trip. 

Dr. Kossover: I think that in her case, 
the onset of the acute infection, whether 
gastroenteritis or cholecystitis, is the rea- 
son for marked increase in blood sugar 
and for the glycosuria. 

Dr. Jacobs: Do you believe it likely 
that she will continue to adhere to a 
good program? 

Dr. Kossover: No, I don’t think that 
she will be able to stay on a 1200-to- 
1500 calorie diabetic diet; but I think 
that the diet she will stay on, combined 
with the use of Diabinese and the dosage 
of 500 mg a day, should be adequate to 


96 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Touro Infirmary 


keep her from going into ketoacidosis, 
and should control her diabetes fairly 
well. 

Dr. Paterson: When I talked to the 
patient, I likened this to a very small 
stroke in a nerve instead of the brain; 
but I told her that she should regard this 
as being a warning that she must look 
after her diabetes and keep it well con- 
trolled. It seemed to me that she under- 
stood the seriousness of this. 

Dr. Ronald Radzikowski: Do you 

think that the control of diabetes actual- 
ly correlates between peripheral neurop- 
athy and peripheral vascular disease 
and ascribed changes? 

Dr. Paterson: I would say that pa- 
tients who have good control of diabetes, 
have less trouble with neuropathy. 

Dr. Patrick Morgan: I read recent- 
ly that certain studies showed a strong 
correlation between blood sugar levels 
and persistence of symptoms of neurop- 
athy. Consistently, symptoms abated 
as blood sugar levels diminished. 

Dr. Jacobs: Do you believe that the 
ability to follow a diet or medical in- 
structions is correlated more with the pa- 
tient’s intelligence, or with factors other 
than the patient’s intelligence? 

Dr. Paterson: I don’t think there is 
any simple answer to the question that 
you raise or that it is a matter of the 
patient’s intelligence or of his motiva- 
tion. I recently saw a student from the 
Tulane Undergraduate School who has 
juvenile diabetes. His brother has dia- 
betes, and everyone in the family has the 
disease. He told me that as an adoles- 
cent he had a terrible time with diabetes. 
He was in and out of acidosis all the 
time, and was hospitalized frequently. 
This was not resolved until he spent a 
summer in a camp for diabetics. There 
he learned to deal with his problem and 
to become motivated in the treatment. 
His parents, being emotionally involved 


O) First year medicine resident, Touro Infir- 
mary. 

O) Intern, Touro Infirmary. 


with him, couldn’t fulfill the necessary 
therapeutic role. Once he went to the 
camp, he managed to control his diabetes 
beautifully; so for about four years he 
has not had one bit of trouble. 

Dr. Alfaro: I think that whether the 
patient has symptoms or not is probably 
the most important factor in following 
instructions. I have encountered many 
diabetics in the clinic, whom I asked : 
“Why do you keep eating, gaining 
weight? Why do you eat ice-cream every 
night?” They say, “Well, that is no 
problem with the insulin. The next day 
when my blood sugar goes up, I take 
more insulin ; and the problem is solved.” 

Dr. Jacobs: Dr. Paterson, does this 
episode for our patient mean that she is 
more vulnerable to a very serious form 
of neuropathy? 

Dr. Paterson: No, I don’t think this is 
necessarily so. She may not have any 
more trouble with this at all. She has an 
increased risk over a non-diabetic of the 
same age. 

Dr. Juan Escarfuller: Suppose a pa- 

tient develops neuropathy, how would 
you make a differential diagnosis with 
multiple sclerosis ? 

Dr. Paterson: Well, she is old for the 
onset of multiple sclerosis. The onset at 
the age of 53 is extremely rare. If the 
oculomotor palsy were due to MS, the 
disease would presumably have to in- 
volve the tract of the 3rd nerve within 
the brain, and as an isolated sign of MS 
this is unusual, even in young people. 

I would just like to make a philosoph- 
ical comment at the end, and wonder if 
some of you have read that because of 
the fact that diabetes is genetically de- 
termined we have reached a point where 
before long the majority of the popula- 
tion of the country is going to have dia- 
betes. In some ways, it just sounds un- 
believable that anyone would criticize 
Banting for discovering insulin ; but be- 
cause it has saved so many lives, people 


Intern, Touro Infirmary. 


March, 1974 — Vol. 126, No. 3 


97 


MEDICAL GRAND ROUNDS— Touro Infirmary 


who would have died from diabetes have 
survived to reproduce themselves to the 
point that the incidence of diabetes is 
now becoming a major problem. There 
is no doubt about it. 

Editor’s Note: The traditional view 

holds that long-standing and poorlj^ con- 
trolled diabetes is the usual cause for 
neuropathy; but several recent series of 
studies have clearly established neurop- 
athy as a concomitant, not a complica- 
tion of diabetes. There has been delin- 
eated a “hyperglycemic neuropathy” as 
well as one precipitated by adequate 
therapy for hyperglycemia. We should 
follow Ellenberg^ who speaks of “the 
diabetic neuropathies” and maintains 
that diabetes mellitus is a generalized 
disease wherein neuropathy is indepen- 
dent of the presence, the degree or the 
duration of hyperglycemia and glyco- 


suria. Increased retention of vibratory 
sensations during ischemia is a phenom- 
enon which may be recognized at the 
onset of diabetes. Symmetrical periph- 
eral neuropathy often suggests diabetes ; 
any patient with bilateral absence of 
knee jerks and ankle jerks deserves a 
search for diabetes even to the extent of 
a glucose tolerance test. Because neurop- 
athy may have preceded the onset of 
chemical or overt diabetes, the practi- 
tioner must remember that: 1) Rever- 
sible neuropathy may be the forerunner 
of irreversible neuropathy; and 2) Con- 
trol of the blood sugar level from an 
early stage in the disease may retard 
progressive damage. 

Reference 

1. Ellenberp M : Neurolofrical changes in early dia- 

betes. Advances in Metabolic Disorders 2: (Supplement 2) 
459. 1973 


98 


J. Louisiana State M. Soc. 



ocioeconomic 



By LEON M. LANGLEY, JR. 


To Ease the Growing Tensions Between Hospital Medical Staffs and governing 
bodies, the Joint Commission on Accreditation of Hospitals has adopted addi- 
tional interpretative language for its standards governing body and manage- 
ment and medical staff sections of the Accreditation IManual for Hospitals. They 
state that physicians and dentists employed by the hospital in a purely adminis- 
trative capacity with no clinical duties are subject to the regular personnel pol- 
icies of the hospital and need not be members of the medical staff. Those physi- 
cians and dentists whose duties are medico-administrative and include clinical 
responsibilities must be members of the medical staff. Termination of employ- 
ment of a physician or dentist in a medico-administrative position shall be sub- 
ject to review by a joint conference of hospital governing board representatives 
and representatives elected by the medical staff as a whole. When the action in- 
volves the individual’s medical competence, the medical staff shall provide for a 
review of the decision, including the right to hearing if requested by the individ- 
ual. If the reason for the action is purely administrative, the governing board 
shall follow its usual personnel policies. These provisions will be added at the 
conclusion of the interpretation of Standard 8 of the governing body and man- 
agement action. The same basic additions will be made at the medical staff se- 
lection portion of the interpretation of Standard 3. 

The American Hospital Association recently issued its Guide for Preparation of Con- 
stitution and Bylaws for General Hospitals. The document brings AHA policy 
into close correlation with the Joint Commission on Accreditation of Hospitals’ 
Formulation of Medical Staff Bylaws, Rules and Regulations. The AHA guide 
suggests that physicians be considered along with other community leaders for 
membership on governing boards, wh ether or not they are members of the hos- 
pital’s medical staff, and that members of the governing board be limited to two 
terms of three years with eligibility for re-election after at least one year out of 
office. It also suggests that medical staff members not on the governing board 
be permitted to serve on board committees; and that the joint conference com- 
mittee should be the focal point for liaison between the governing board and the 
medical staff. According to the Guide, the governing board should assign rea- 
sonable authority to the medical staff, for insuring appropriate professional care 
and the medical staff should conduct an ongoing review and appraisal of the 
quality of care. 

The Public Private Health Spending Ratio Continued its trend toward more govem- 
ment spending during the fiscal year ending last July 7. The Social Security Ad- 
ministration’s preliminary figures show that the nation’s outlay for health was 
$94.1 billion, an 11% increase over fiscal 1972. The rate of increase was the 
lowest in several years and the proportion of health spending to the Gross Na- 
tional Product remained at the 1972 level, 7.7%. In fiscal 1973, 60.1% of the 
spending was private and 39.9% was public. The ratio in 1928 was 86.7% pri- 
vate and 13.3% public. Federal spending rose almost $3 billion, to an estimated 
$24.6 billion. State and local spending was $12.9 billion, up more than $1.5 bil- 
lion. Of the $94.1 total in fiscal ’73, $36 billion went for hospital care and $18 
billion for physicians’ services, compared with $32.6 billion and $16.6 billion in 


1972. 


March, 1974— Vol. 126, No. 3 


101 



Louisiana State Medical Society 
Professional Liability 
Insurance Program 

It's Your Program 

By participating in the LSMS professional liability insurance program, 
you are doing more than simply buying high quality insurance at a fair 
price. You are participating in a physician managed effort to control 
present and future professional liability problems. 

Officially Endorsed 

The Hartford professional liability insurance program is the only pro- 
fessional liability insurance plan officially endorsed and sponsored by 
the LSMS. 

Administered by 

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New Orleans. Louisiana 70130 
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Guest (^ditoriui 


PSRO an Invalid Concept 


Genesis of PSRO Concept 

Certain social medical programs, pro- 
mulgated in the 1960s, resulted in such 
massive cost overruns that the Senate Fi- 
nance Committee began pressing for legis- 
lation to rein the cost runaway. Even the 
most liberal spending congressman be- 
came mindful that cost estimates of 
health care legislation already enacted 
were staggeringly underestimated. The 
liberal principle of “tax and spend” was 
reexamined as its faulty nature surfaced 
in the hard school of practical application. 
A simple direct solution of restructure and 
retraction of certain medical care social 
programs, particularly the ones so highly 
advocated by presidential aspirants, was a 
complex task. A concept to reduce cost by 
computer technology along with vast phy- 
sicians-committee hours was enacted into 
law. A costly venture was birthed to 
achieve cost control of medical care-PSRO. 

This is indeed a new and untried con- 
cept. It places the health care industry in 
direct battle with a machine born of the 
mind of man. No one has tested the valid- 
ity of the concept. Congress, seeking pri- 
marily to save top dollars, mandates a law 
in haste before anyone is sure that it will 
save as much as it costs. The act is passed 
in the fading moments of a congressional 
session without any public hearings. Sure- 
ly, this alone bears testimony to the in- 
validity of the PSRO concept. Truly, the 
genesis of the PSRO law is a manifesta- 
tion of the self-destruction course on which 
our society has chosen to embark. 

Theory and Principles of PSRO 

It was rationalized by liberal minds that 
the failure of the social programs of the 
1960s was the fault of the physician pro- 


F. MICHAEL SMITH, JR., MD 
Thibodaux 

vider and not the inherent weakness of the 
progi’am. 

Rising costs of medical care, in an in- 
flation troubled economy, were blamed 
solely on the physician. He was reasoned 
illogically to be the “broker” of all health 
care. The assumed greed of physicians 
was given much press coverage during 
hearings before the Senate Finance Com- 
mittee. A small percentage of physician 
“cheaters” was presented in a manner to 
explain temporarily the cost overruns. 
Such programs of opprobrium were not as 
successful as politicians would have de- 
sired. Dr. Gallup in nationwide polls 
stated that the public at large continued 
to rate physicians as “number one” in pub- 
lic confidence. 

The theory of the PSRO concept is in 
reality simple. Since massive numbers of 
physicians are assumed fraudulent, and 
for self serving causes run up the costs of 
medical care, then by monitoring physi- 
cian perfoiTuance and mandating compli- 
ance with “norms and standards,” it is 
assumed medical care costs will be con- 
trolled. Later I will present hard evidence 
that this simply is not so. 

The mechanics of PSRO are as follows: 

a. Creation of explicit criteria by mor- 
tal minds. 

b. Preprogram the computers with this 
data. 

c. Feed in the individual physician’s 
performance. 

d. When and if b and c conflict, then 
bring peer pressure, fines, and punitive 
measures to bear on the nonconformist. 
PSRO by this simple mechanism defines 
the lines of battle between man and ma- 
chine. 


March, 1974 — Vol. 126, No. 3 


103 


GUEST EDITORIAL 


PSRO does not monitor physician per- 
formance per se, but rather monitors rec- 
ords created by physicians. Like all other 
endeavors of man, physicians are much 
better doers than they are recorders. Who 
among us is really competent to pre- 
program computers with ideal explicit 
criteria that rise above the fallibility of 
the physician ? Let us not forget that man 
is the creator and source of knowledge for 
the computer, and ultimately the com- 
puter’s ideal information is as ideal as the 
cranial or programming capabilities of 
man. 

Medically speaking, is this not really a 
fluid function? Do we still manage pneu- 
monia today as we were taught in school? 
Is it really possible to construct in man’s 
mind ideal criteria, then program the com- 
puters in a time frame before obsolescence 
of these criteria makes them nonvalid? 

Since PSRO monitors records and not 
physician performance, how can it detect 
or prevent fraud? Would not the very 
mechanics of PSRO give certification to 
a fraudulent individual who contrived to 
create an ideal record that adhered to the 
known ideal criteria? 

Physicians function in three basic areas: 

a. Diagnostic performance functons. 

b. Manual-dexterity performance func- 
tions. 

c. Case management performance func- 
tions. 

PSRO can only monitor the last of these. 
There is no technology in the PSRO con- 
cept to monitor the first two which are 
the most important in quality of care as- 
sessment. Once again, functions a and b 
are fluid and are not ideal measures to be 
found in computer circuits. Even to mon- 
itor the last function of case management, 
PSRO must begin with the invalid as- 
sumption that the diagnosis is correct. 
How stupid becomes the whole process of 
PSRO when one considers that a costly 
process was carried out wherein the pa- 
tient died from a different disease than 
that which the computer was led to believe 
the patient had. 


Conclusion 

Recently, I visited an active ongoing 
computer data processing system applied 
to the effort to monitor physician per- 
formance as to quality assessments. The 
system had been funded under EMCRO 
funds. The two most significant observa- 
tions made there were that far less than 
5 percent of physicians monitored were 
found to be substantially out of line with 
what they felt was ideal case management. 
Secondly, and perhaps most important of 
all, was the fact that fraud was almost 
nonexistent. In nearly three years of ef- 
fort, not one case of fraud was found that 
required removal of a physician’s license. 
The extrapolation of this nationally ne- 
gates conclusively the charge that there is 
widespread fraud among physicians. 

Louisiana has chosen a sensible course. 
We should continue to resist PSRO and 
seek its repeal. 


<5=3 C=0 



104 


J. Louisiana State M. Soc. 


a 


rganiza u on 


tii 


^ecli 


on 


The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


MECO PROJECT IN LOUISIANA 
FOR 1974 

MECO (Medical Education & Committee Ori- 
entation) under the direction of the statewide 
SAMA chapters is reorganizing its summer pro- 
gram for 1974. MECO is a nationally coordi- 
nated network of educational programs for pre- 
clinical medical students. Based in a community 
hospital, group practice or private practice, the 
summer extramural program offers the student 
an exposure to the community and to the com- 
munity health system. Programs include rotation 
through both clinical and non-clinical areas of the 
hospital or clinic, observation and participation 
in physician’s offices, and study of the function 
of health-related agencies and institutions in the 
community. 

The primary objective of MECO in Louisiana 
will be to redistribute physician manpower in the 
state by exposing the student, at an early point 
in his training, to the health care system of local 
communities, thus affording him an awareness 
unattainable in his formal medical training. 
MECO is endorsed by both the Louisiana State 
Medical Society and Louisiana Hospital Associa- 
tion, and the program should offer great poten- 
tial for medical students, private practitioners 
and health care institutes throughout the state. 
We are actively soliciting as great a participation 
as possible from physicians and local community 
health centers in Louisiana. 

For further information on establishing a 
MECO community project or any other general 
information about the program contact: J. 

Lemein, Louisiana MECO Director, Box E-9, 
Tulane Medical Center, New Orleans, La. 70112. 


HEALTH OFFICIAL WARNS OF 
ASPHYXIATION PERIL 

As people begin to button up their overcoats 
and their homes against cold weather, they should 
take one other measure, says Dr. Helen L. Bruce, 
St. Louis’ acting health commissioner. And that 
is: Mount a mental alert against the danger of 
death by asphyxiation. 

“Carbon monoxide is a colorless, tasteless, 
odorless gas,” she pointed out. “Normal combus- 
tion produces only an insignificant amount of it, 
but incomplete combustion of any fuel increases 
the amount.” 

CO is an insidious killer. 

“The early stages of poisoning are indicated by 


headache, dizziness and sleepiness,” Dr. Bruce 
said. “As more gas is absorbed, symptoms include 
nausea, vomiting, fluttering and throbbing of the 
heart, and finally unconsciousness and death. 

“These symptoms resemble those of many com- 
mon diseases, and this makes it possible for a per- 
son or family to fail to recognize that they are 
being poisoned. Each year, more than 1,500 
Americans die from carbon monoxide poisoning, 
about 900 of them in their homes. And many of 
these deaths could have been prevented.” 

Fuel-burning heating systems should be checked 
at least once a year and kept in good repair and 
adjustment. Dr. Bruce advised. 

The flames on most burners using natural gas 
or liquefied petroleum gas should burn steadily 
with a clear, blue flame. A wavering, yellow 
flame on the normal gas burner means that it 
may be giving off excessive amounts of CO. A 
clear, yellow or orange, steadily burning flame is 
an indication of good combustion of fuel oil- 
burning equipment. 

Carbon monoxide acts somewhat like a biolog- 
ical bully : when breathed into the lungs, it crowds 
oxygen molecules off red blood cells, because it 
forms a tighter bond with the cells. In fact, CO 
affinity for the cells is more than 200 times as 
strong as that of oxygen. Dr. Bruce said. 

“When this happens, the amount of oxygen 
carried through the body is insufficient,” she 
said, “and vital bodily functions are impaired. 
Exposure to high levels of CO can quickly cause 
unconsciousness and death, depending on the 
length of exposure, and the physical condition 
and activity of the victim at the time of ex- 
posure.” 


PMA ASKS FOR TOP PRIORITY IN 
ALLOCATION OF FUELS AND 
PETROCHEMICALS 

The pharmaceutical industry recently asked 
for top priority in the allocation of fuels and 
petrochemicals needed by manufacturers in order 
to avoid shortages of critical prescription drugs. 

At an energy crisis hearing before the Sub- 
committee on Health (Senate Committee on La- 
bor and Public Welfare), C. Joseph Stetler, presi- 
dent of the Pharmaceutical Manufacturers Asso- 
ciation, said “a serious fuel or petrochemical 
shortage in the drug industry would constitute a 
public health hazard of serious dimensions,” and 
called for “immediate directives from appropri- 


March, 1974 — VOL. 126, No. 3 


107 


ORGANIZATION SECTION 


ate governmental authority.” 

Stetler noted that the industry’s needs for 
petrochemicals and fuels were relatively small, 
but that the impact of their curtailment “could 
be immense and certainly vastly disproportionate 
to that suffered by most other industries,” 

Calling for moderation, Stetler said “the situa- 
tion we face can be described with deliberacy and 
without overstatement. It is manageable and does 
not warrant sensationalism. If we can demonstrate 
the fact that our priorities can be met with very 
minor effect on other regular and priority needs, 
we are confident that no significant disruptions 
in the availability of medicines will take place.” 
Failing suitable resolution of the matter, Stet- 
ler asserted, there could be “a broad spectrum 
potential shortage of important drugs: antibiotics, 
vaccines, insulin, steroids, cardiovascular agents, 
sterile large volume parenteral solutions, anal- 
gesics, and blood derivatives.” 

Moreover, he said, there could be disruptions 
of research programs. “Our laboratories require 
exceptionally well-controlled environments for 
animal colonies and experimental procedures. 
Maintenance of such facilities and experimental 


conditions depends on adequate energy sources. 
Unless laboratory standards can be maintained, 
research results of ongoing long-term studies 
will be lost, and new projects will have to be 
curtailed,” 

Both fuels and petrochemicals are in short sup- 
ply, the PMA statement reports; it asks that the 
new regulations concerning mandatory petroleum 
allocations, including petrochemical feedstocks, 
designate pharmaceutical manufacturing as an 
essential industry with priority allocation. 

Additionally, the industry asked for “a higher 
priority position than that designated” in the reg- 
ulations, and an allocation for current needs, 
rather than one based on past usage. 

Stetler said PMA has made appropriate repre- 
sentations to the Administrator of the Office of 
Petroleum Allocation, the Administrator of the 
Federal Energy Office, and the Assistant Secre- 
tary of Health. “All of these actions,” he said, 
“have been taken to ensure that those respon- 
sible for coordinating the national energy effort 
take the steps needed now to assure continued 
full production of essential medicines and medi- 
cal-surgical supplies.” 


At Your Service in 
The Peiican State 


In the region* named by LaSalle 
in honor of Louis XIV and 
sometimes called The Creole 
State because of its many 
descendants of early French and 
Spanish settlers . . . 


PHARMACEUTICAL DIVISION 

MARION 

LABORATORIES, iNC. 

KANSAS CITY NfO. _64137 

is represented by . . . 




John Able 


Dick Sensat 


Dennis Spencer 


*For more information on the history of your 
state, write Professional Services, 

Marion Laboratories, Inc. 



Terry Whitney 


These men bring you 



Harry Wilder 



108 


J. Louisiana State M. Soc. 



ORGANIZATION SECTION 


Stetler assured the subcommittee that the 
pharmaceutical finns are taking and will continue 
to take eveiy step to conseiwe available fuels. 


AMERICA’S CLIMBING HEALTH 
CARE COSTS 

New and improved drug products are the best 
hope of reducing America’s climbing health care 
costs, a Senate investigating subcommittee was 
told recently. 

President C. Joseph Stetler of the Phanna- 
ceutical Manufacturers Association, testifying 
before the Senate Subcommittee on Health, 
pointed out that the new drug discoveries have 
been a major contributor to improving health 
care, especially in the post-WWII era, and that 
drug prices have held stable in a period of soar- 
ing inflation. 

But, he warned, America is falling behind for- 
eign competitors in the rate of pharmaceutical 
innovation, adding that the industry’s pattern of 
discovery of new drugs and the stable prices of 
medicines are threatened by proposals to reduce 
incentives for drug producers to continue their 
massive research programs. 


“Price setting, dilution of patent rights, or a 
government take-over of research and develop- 
ment or promotional activities,” suggested by 
some, would be self-defeating and lead to higher 
prices and lower productivity, Stetler said. 

The industry’s testimony came on the second 
day of an opening three day round of hearings 
on the pharmaceutical industiy called by Sen. 
Edward M. Kennedy (D.-Mass.). 

Thb PMA comments centered on the recom- 
mendations of a 1969 HEW Task Force on Pre- 
scription Drugs, and on the impact of amend- 
ments to the Food, Drug and Cosmetic Act which 
followed in the wake of Senate hearings in the 
early 1960s. 

Stetler warned that promises of cheaper drugs 
through “generic” rather than braiid-name pre- 
scribing are unfounded, and that the equivalency 
of drug products of the same generic composition 
has not been proved. He underscored the need 
for the physician to know and have confidence 
in the identity of the manufacturer, and that 
forced generic prescribing would deprive the pa- 
tient of his physician’s medical judgment. 

Although the industry’s dollar investment in 



Puts comfort 
in your prescription 
for nicotinic acid 


March, 1974— Vol. 126, No. 3 


109 


ORGANIZATION SECTION 


research is continuing to climb, Stetler testified 
that fewer American pharmaceutical firms are 
sponsoring such activities due, in part, to the 
tangle of government delays and regulations. 

“From 1940 to 1970, U.S. firms originated 70 
percent of the 809 drugs introduced in this coun- 
try,” he said, “but from 1971 to 1973, they orig- 
inated only 37 percent, or 10 of the 27 new drugs 
introduced.” 

Calling on Congress for “a favorable policy on 
innovation,” Stetler emphasized that a public 
policy commitment to drug research is needed. 
R&D costs per new drug entity may be $40 mil- 
lion, and the laboratory to patient time lag may 
be 10 years, by 1977 if the present trend con- 
tinues, he said. 

“Drug products control illness, alleviate suf- 
fering and reduce the cost of illness,” he said. 
“Our nation cannot afford to make drug research 
so unattractive to sponsors, when the potential 
benefit to patients is so great.” 

Turning to the Food and Drug Administration, 
Stetler described it as improving, but under- 
staffed and underfunded, noting that its work- 
load has doubled in the past five years. Further- 
more, fewer manufacturing plants are being in- 
spected annually, and some plants of smaller man- 


ufacturers are not inspected at all for periods of 
up to five years. 

The PMA president asked Congress for “a 
thorough, multi-disciplined review of the entire 
regulatory process, comparing the American ap- 
proach to those of other highly developed na- 
tions.” This, he said, would produce “a more 
precise evaluation of FDA’s role in the research 
environment.” 

Noting that the United States has the most 
highly regulated process of drug development 
and manufacturing control in the world, Stetler 
said some 200 comprehensive regulations, imple- 
menting the 1962 amendments to the drug laws, 
have been promulgated. There has been “con- 
structive effort” by both FDA and the drug in- 
dustry, with joint working parties and greater 
use by FDA of outside expert advisors “thus in- 
creasing the quality of (FDA) decisions and ex- 
pediting scientific and administrative determina- 
tions.” 

The PMA, whose 110 member firms produce 
95 percent of America’s drug supply, pledged its 
“full support to a rational exploration” of the 
industry’s problems as the Senate hearings con- 
tinue. 


110 


J. Louisiana State M. Soc. 


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CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every month 


Calcasieu 

Fourth Tuesday of every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday of every month 

Baton Rouge 

Jackson- Lincoln- Union 

Third Tuesday of every month 
except summer months 

Jefferson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every other month 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

1 ndependence 

Terrebonne 

Third Monday of every month 


Second District 

Third Thursday of every month 


Shreveport 

Quarterlv — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday ot every month 



AMERICAN RHINOLOGIC SOCIETY 
MEETING 

The American Rhinologic Society and the Illi- 
nois Masonic Medical Center will present an in- 
troductory course in (A) Functional Corrective 
Surgery of the Nasal Septum and the External 
Nasal Pyramid; (B) Rhinomanometry and Naso- 
Antral Manometry, and (C) Basic Principles of 
Respiratory Physiology and Fundamental Diag- 
nostic Tests — Pulmonary, Cardiac, Blood Gas 
Analysis, Nasal Function Tests, and introducing 
Naso-Pulmonary Function Tests. Part C is 
planned and designed for all members of the 
medical profession, especially those in general 
practice. It will be given in four sessions on 
April 2-5 in conjunction with the annual Midwest 
Clinical Conference (Chicago Medical Society) 
and the Illinois State Medical Society’s 132nd 
annual meeting. Courses will be held at the Illi- 
nois Masonic Medical Center in Chicago. 

Registration fee for the full course is $350.00 
and for Part C only, $50.00. 

For further information contact American 
Rhinologic Society, Mrs. Frances Nizenkoff, Cor- 
responding Secretary, 530 Hawthorne Place, Chi- 
cago, Illinois 60657. 


HEALTH HAZARD REPORTED IN DRUG 
USED FOR TRAVELER’S DIARRHEA 

Americans traveling abroad are advised to 
avoid buying non-prescription drugs for self- 


treatment of traveler’s diarrhea. 

Many of these products sold in other countries 
contain a drug that may cause serious neurolog- 
ical upsets and even death, says the report by 
Godfrey F. Oakley, Jr., MD, of the Center for 
Disease Control at Atlanta and the University of 
Washington Medical School at Seattle. 

The offending drug is known to pharmacolo- 
gists and physicians as iodochlorhydroxyquin. It 
is sold under more than 50 different trade names 
throughout the world, in many countries without 
prescription. In the United States it is available 
only on prescription and is used principally to 
treat amebic dysentery. 

Actually, these drugs do not help overcome 
traveler’s diarrhea and should not be used for 
this complaint, says Dr. Oakley. 

Unregulated use of products containing this 
drug can cause an impairment of the senses, par- 
ticularly the sense of touch. More seriously, they 
can cause eye damage that sometimes leads to 
blindness. In severe cases the result may be 
death, the report says. 

“Because the drugs are sold under a large 
number of different trade names, an American 
traveling out of the country may find it difficult 
to avoid being exposed to the drug if he buys 
any over-the-counter remedy for diarrhea. It 
seems prudent, therefore, to advise travelers to 
avoid buying any over-the-counter products,” 
Dr. Oakley says. 


112 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


$6.00 Per Annum, $1.00 Per Copy Am?TT 1 Q7zL Published Monthly 

Vol. 126, No. 4 iAJrxv±J_j, Lu I ^ 1700 Josephine Street, New Orleans, La. 70113 


Statewide Physician Manpower Planning in Louisiana: 
Basis for Planning and Primary Studies* 

• . This report has indicated that Louisiana is facing several 

significant manpower production problems in its preparation for the 


physician services it needs in 1982." 


JN MARCH of 1972 a special committee, 

sponsored by the Louisiana Regional 
Medical Program and the State Office of 
Comprehensive Health Planning, was 
formed consisting of representatives of 
those institutionsf with major interests in 
Louisiana physician residency programs. 
The overall goal of this committee is to 
develop a strategy for the design and allo- 
cation of physician residencies consistent 
with the state’s needs for various types of 
physicians. The methods to be used to 
achieve this goal include: 

1. Description of the physician man- 
power production system that presently 
exists in Louisiana. 

2. Examination of the effectiveness of 
the present manpower production system. 

3. Prediction of future needs of Lou- 
isiana for physician manpower through 
1982. 

4. Investigation of alternative meth- 
ods to alter the physician manpower pro- 
duction system to meet the present and 
future needs of Louisiana. 

The purpose of this article is twofold: 
first, to provide a basis for studies to be 
undertaken and second, to report the re- 


ROBERT W. SAPPENFIELD, MD 
MICHAEL H. MOSKOWITZ, MPH 
PAMELA S. ALLISON, BA 
YOGESH C. PATEL, PhD 
WILLIAM H. STEWART, MD 
New Orleans 

* This report was aided with funds from the 
Bureau of Health Manpower Education (contract 
No. NTH 72-4340) awarded to the Louisiana Re- 
gional Medical Program in cooperation with the 
State Office of Comprehensive Health Planning 
to support the planning activities of the Commit- 
tee for Statewide Planning for Physician Resi- 
dency Programs. The AMA has contributed 
immeasurably by making available various data 
collected in its annual suiwey of physicians. 

Dr. Sappenfield is the Chairman of Committee, 
Associate Dean of Student Affairs, LSU School 
of Medicine, New Orleans. 

Dr. Moskowitz is a medical student, LSU 
School of Medicine, formerly with the Louisiana 
Regional Medical Program, New Orleans. 

Ms. Allison is with the Louisiana Regional 
Medical Program, New Orleans. 

Dr. Patel is with the LSU School of Medicine, 
Department of Biometry, New Orleans. 

Dr. Stewart is the Chancellor, LSU Medical 
Center, New Orleans. 

Tables cited are available upon request. 

t Institutions represented on the committee : 
Louisiana State Medical Society, Louisiana State 
University Medical Center, Tulane University 
School of Medicine, Confederate Memorial Medi- 
cal Center, Charity Hospital of Louisiana, Veter- 
ans Administration Hospital, Ochsner Clinic, 
Touro Infirmary, Southern Baptist Hospital, 
Health Education Authority of Louisiana, 
LHSRSA Division of Hospitals, and Division of 
Health Maintenance and Ambulatoiy Patient 
Seiwices. 


April, 1974 — Vol. 126, No. 4 


113 


PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


suits of our initial studies. It will include 
the presentation of a g’raphic model to 
illustrate Louisiana’s physician manpower 
production process, the use of already ex- 
istent data to quantitate the various in- 
flows and outflows of the model, and the 
results presently available from the anal- 
ysis of data collected from all graduates of 
Louisiana medical schools and all physi- 
cians practicing in Louisiana. 

The Graphic Model 

A schematic diagram entitled “The 
Graphic Outline of Physician Manpower 
Production Process” was developed (Fig 
1). It is principally based on the concept 
of the “resident graduate” as the finished 
product of the system, ready to enter a 
lifetime of practice in his area of compe- 
tence. As can be seen, it is divided into 
three major time periods: namely, four 
years of medical school, an average of 
three to four years of postgraduate train- 
ing including internship and residency, 
and the full time active professional life 
which is estimated to be approximately 35 
years. The various arrows in the outline 
demonstrate the inputs and outputs of the 
manpower production system. 

The most important point of entry, 
quantity- wise, is at admission. A number 
of trainees come after medical school 


training elsewhere for postgraduate train- 
ing and then remain in Louisiana for prac- 
tice, or come from elsewhere after com- 
pleting their postgraduate training and 
then find a place for practice in Louisiana. 
The following losses occur in terms of phy- 
sicians providing professional services in 
Louisiana. The earliest loss covers drop- 
outs or academic failure in medical school. 
A second loss occurs when young physicians 
leave after medical school for postgrad- 
uate training elsewhere and never return 
to Louisiana. The third major point of 
egress is after residency when they leave 
for practice in a state other than Louisi- 
ana. A small loss occurs from physicians 
who change location of practice to another 
state after entering practice in Louisiana. 
This usually occurs within the first few 
years of practice if it is to occur at all. 
The final point of egress, of course, is 
death or retirement. 

Three examples of common pathways 
are listed below: 

1) Those who are admitted to a medi- 
cal school in Louisiana, take their post- 
graduate training here and stay in Louisi- 
ana for their professional practice careers 
This is the largest of the groups that we 
are dealing with in this model. 

2) Those physicians who complete 


GRAPHIC OUTLINE OF PHYSICIAN MANPOWER PRODUCTION PROCESS 


Come for Postgraduate 
Training and 
Remain for Practice 


Leave Only for Postgraduate 
Training and Return for Practice 


All Medical Training 
Elsewhere, Then 



Losses due to: 
I.) Dropouts 
2)Acodemic 
Failure 


and Never Return 


Leave for Practice 


Leave State or 
Leave Medical 
Profession 


Fig 1. Statewide physician manpower planning in Louisiana; basis for planning and primaiy 
studies. 


114 


J. Louisiana State M. Soc. 



PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


medical school here, then go elsewhere for 
their postgraduate training either in part 
or in full and then return for their profes- 
sional practice location in Louisiana. 

3) The group that are trained else- 
where, come here for graduate training, 
and leave for some location other than 
Louisiana for their professional practice. 

There are many variations of the themes 
just described, but this graphic outline 
does illustrate the major points of en- 
trance and loss in the manpower produc- 
tion process as it affects Louisiana. 

Present Status of Louisiana Health 
Manpower Production System 

The data analyzed from the AMA on 
graduates from Louisiana medical schools 
and on physicians practicing in Louisiana 
as of December 31, 1972 reveal the follow- 
ing information: There are 6,700 nonfed- 
eral practicing physicians who are grad- 
uates of medical schools located in Louisi- 
ana (excluding present interns and resi- 
dents) . Of these 6,700 graduate physicians 
2,628 (39.2 percent) are presently prac- 
ticing in Louisiana. This is lower than the 
overall rate of retention found by Scheff- 
ler.’ As can be seen in Table 1, “Distribu- 
tion of Nonfederal Physicians Graduated 
from Louisiana State Institutions by Year 
of Graduation and Practice State, Decem- 
ber 31, 1972,” the percentage of graduates 
from Louisiana medical colleges remaining 
in the state has been steadily increasing. 
This is partially due to the founding and 
increased enrollment of the Louisiana 
State University Medical School in New 
Orleans. The percentage remaining in 
Louisiana should continue to increase due 
to the founding of the LSU Medical School 
in Shreveport. It is unknown whether the 
48.9 percent of the gi’aduates from Louisi- 
ana medical colleges during the period 
1965-1969, who are now practicing in Lou- 
isiana, is an actual forecast of the percent- 
age who will be practicing here when all 
interns and residents have finished their 
training programs. If this is the trend, 
Louisiana is in the position of retaining 
a larger percentage of the physicians grad- 


uated from its medical colleges. This is 
not the case in the rest of the United 
States. According to Scheffler,^ in 1963, 
approximately 44.2 percent of all physi- 
cians in the United States were practicing 
in the states where they graduated from 
medical school. In 1967, only 43.0 percent 
were practicing in the states where they 
attended medical school. (If this decrease 
in percentage were due only to the prac- 
tice location decisions of new practitioners 
during the years 1963-1967, then only 25.3 
percent of the new medical practitioners 
practice in the states in which they grad- 
uated from medical college.) 

Table 2, “Distribution of Nonfederal 
Physicians in Louisiana by State of Grad- 
uation and Year of Graduation, December 
31, 1972,” shows that of the 3,742 active 
nonfederal physicians practicing in Lou- 
isiana, 70.2 percent are graduates of Lou- 
isiana medical schools, and 29.8 percent 
are graduates of other medical schools. 
When looking at the trend, it can be seen 
that with one exception the percentage of 
Louisiana graduates among the physician 
population increased on a percentage basis 
to 75.3 percent by 1955-1959. The period 
1960-1964 shows a decrease to 65.3 percent 
educated in Louisiana medical colleges. If 
the findings for this time period in Table 
1, that the percentage of graduates from 
Louisiana medical colleges staying in Lou- 
isiana for practice is increasing, are cou- 
pled with the findings in Table 2, that the 
percentage of physicians practicing in 
Louisiana who graduated from Louisiana 
medical colleges is decreasing, then the 
major explanation would seem to be in- 
creased attractiveness of Louisiana to both 
Louisiana and other graduates. Although 
the total number of graduates practicing 
out of Louisiana (Table 1) decreases in 
the time period 1965-1969, it must be re- 
membered that a large percentage of these 
physicians are still involved in their post- 
graduate professional training or are ful- 
filling their military obligations. This fac- 
tor should be remembered when interpret- 


April, 1974 — VoL. 126, No. 4 


115 



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116 


J. Louisiana State M. Soc. 


PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


ing- information concerning recent grad- 
uates. 

The question of possible shifting of phy- 
sicians from direct patient care to non- 
patient care activities deserves considera- 
tion. After removing interns, residents, 
inactive and nonclassified physicians, the 
percentage of Louisiana physicians in- 
volved in patient care was about 90.2 per- 
cent for the years 1969, 1970, 1971, and 
1972. Thus, there does not appear to be a 
shifting away from patient care at the 
present time. However, only 81.9 percent 
of the physicians attracted to Louisiana 
from medical schools outside the state are 
presently actively involved in patient care. 
The major non-patient care activities that 
attract these physicians are medical teach- 
ing and medical research. It is noteworthy 
that Louisiana medical schools graduate a 
high percentage of physicians interested 
in patient care, with 92.3 percent of all 
active classified graduates involved in pa- 
tient care services as of December 31, 
1972. 

The next logical question is, does Lou- 
isiana have a sufficient number of post- 
graduate training positions to provide the 
physician specialists the state needs to 
care for its population. The approximate 
number of final year residency positions 
available in Louisiana is 225. This is a 
measure of the capacity for training the 
various types of physician specialists each 
year in Louisiana. If in the future, there 
is to be a residency position open to each 
student graduated from a Louisiana medi- 
cal school, then the number of positions 
now offered is about 100 short of what 
will be needed to accommodate the grad- 
uating class of 1976. It is apparent that 
330 residency positions will be the mini- 
mum needed by 1980, considering the prob- 
able expansion of first-year medical ad- 
missions. 

The distinction between the capacity for 
and the actual production of physician 
specialists is essential. The percentage of 
residency positions offered in the state 
that were filled ranged from 74 percent 


to 78 percent for the years 1965-1969. An 
unusually high percentage of 84 percent 
filled occurred in 1969-1970. Actually this 
was due to a decrease in the number of 
positions offered since the actual number 
filled was similar to that found in the 
other years.- In order to understand the 
problems related to our specialty needs, it 
is necessary to have information concern- 
ing the number of residency positions of- 
fered and filled in each specialty to be 
evaluated. These data are not available 
for consideration at this time. 

Any measurement of the difference be- 
tween capacity and actual production of 
Louisiana’s residency programs must give 
consideration to the effect of training for- 
eign medical graduates. For the United 
States as a whole, the influx of foreign 
medical graduates has increased the per- 
centage of positions filled. There are no 
trend data on the FMG in Louisiana cur- 
rently available. However, for the year 
1969-1970 foreign medical graduates were 
accepted for 92 or 14.5 percent of 636 
places available in all levels of residency 
training. (This contrasts with 33.0 percent 
of all such residency positions filled in the 
United States'^). The attraction of foreign 
medical graduates will not aid in any long- 
term solution for meeting Louisiana’s phy- 
sician manpower needs as long as Louisi- 
ana’s regulations discourage their selec- 
tion of Louisiana for their perm.anent 
practice location. 

Estimates of Future Needs 

Table 3 gives various estimates of the 
overall physician manpower need for Lou- 
isiana in 1982. In determining the base 
ratios for Louisiana and the United States 
(Estimates A and C), physicians included 
are active nonfederal physicians of all .pro- 
fessional activities as of December 31, 
1971.^ Physicians involved in research, 
teaching, or administrative activities are 
included since they, as well as patient care 
physicians, undergo the entire physician 
manpower production process previously 
described. In estimate B, the average pre- 
payment group practice plan ratio of 


April, 1974 — Vol. 126, No. 4 


117 


PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


1/1000 has been adjusted since this ratio 
included only patient care physicians ex- 
clusive of interns and residents.-^ In Lou- 
isiana in 1971, 10 percent of the total 
active classified number of physicians ex- 
cluding interns and residents were in- 
volved in activities other than patient care. 
Assuming that this 10 percent will remain 
constant in 1982, the ratio of 1/900 re- 
flects the adjustment for physicians not 
involved in patient care. 

In Estimate D, the U.S. 1971 Ratio is 
adjusted so as to meet the possible in- 
crease in demand for health care services. 
A 20 percent increase may not be too large 
an estimate for the next ten year period 
if the current trends in increased demand 
continue. In addition to general popula- 
tion growth, one factor contributing to an 
increase in demand for medical care in 
Louisiana in 1982 will be the growth of 
the 65 and over age group® with its above- 
average health needs. Any expansion of 
the Medicare and Medicaid health pro- 
grams will increase the demand for health 
care services from the aged and lower- 
income groups. The expected rise in edu- 
cational level and/or family income will 
probably be followed by increased demand 
by all age groups. Advancements in medi- 
cal technology and consumer health edu- 
cation should continue to increase demand 
for service. Finally, if any of the several 
national health insurance proposals cur- 
rently under consideration is passed be- 
fore 1982, the 20 percent increase in de- 
mand estimate could well be a minimum. 

Louisiana’s need for - physician man- 
power in 1982 according to these four esti- 
mates ranges from 3,937 to 5,632 depend- 
ing on the basis used for projecting need. 
Thus, it can be seen that a large increase 
in physicians’ services or its equivalent 
(allied health personnel, etc.) will be nec- 
essary by 1982. 

Methods for Increasing Manpower 

Table 4 illustrates six possible avenues 
for Louisiana to modify quantitatively its 
physician manpower production process 
using the concepts presented in the graphic 


model discussed earlier. In developing this 
table, it was necessary to use gross ap- 
proximations at certain points since re- 
liable data were not available. Background 
information and assumptions to this table 
include: a) 3,742 active nonfederal physi- 
cians in Louisiana as of December 31, 
1972, (see Table 2); b) Estimated loss of 
3 percent of medical school admissions be- 
fore graduation; and c) An average phy- 
sician “full-time working life” of about 35 
years. 

Illustration A shows the estimated num- 
ber of physicians who will be practicing in 
Louisiana in 1982 if Louisiana continues 
to admit the same number of medical stu- 
dents and continues retaining and attract- 
ing physicians at the same rate as in the 
past. The number of admissions (328) is 
the approximate number of yearly admis- 
sions occurring in the state. The 44.6 per- 
cent retention rate was based on the re- 
tention of about 60 percent for LSU grad- 
uates and 25 percent for Tulane graduates 
over the years and is consistent with re- 
cent rates of retention in Table 1. For the 
time period 1940-1959, the best estimate 
of the number of out-of-state medical 
school graduates entering practice in Lou- 
isiana was 28 per year (see Table 2). 
However, for the 1960-1964 year of grad- 
uation time period, the average was 42 
per year. The latter average is used as it 
is more recent and is consistent with the 
use of maximum estimates elsewhere in 
the table. From the data available, it could 
not be determined at what point in the 
manpower production process these out- 
of-state medical school graduates had en- 
tered the state: for internship, residency, 
or only for practice. 

With the average white male life expec- 
tancy being about 69 to 70 years and with 
most physicians completing residency at 
age 30 or later, there remain about 39 
years for practice. Four years were sub- 
tracted to account for change of profes- 
sion, early retirement, and part-time prac- 
tice. Therefore, it is estimated that there 
is a loss of about 1/35 of the physician 


118 


J. Louisiana State M. Soc. 


PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


population per year. This is a very rough 
estimate of attrition since it does not take 
the age distribution of Louisiana’s physi- 
cians into consideration, but it serves well 
enough for the purposes of illustration. If 
1/35 is lost each year, then after 35 years 
a balance in loss and replacement will be 
reached. These are the 6,440 physicians 
who will be maintained in the long run. 
To determine the number of physicians in 
1982, it was figured that about 34/35 (or 
.9714) of the active physician population 
continues in active practice each year and 
that 184 physicians are entering practice 
in Louisiana each year. Thus, after ten 
years, approximately 4,422 physicians will 
be practicing in the state if Louisiana con- 
tinues to produce, retain, and attract at 
present rates. 

Illustration B indicates that increase in 
retention rate will be necessary if Louisi- 
ana is to achieve the U.S. 1971 Physician/ 
Population Ratio by 1982 (4,693 physi- 
cians) with the same number of medical 
admissions of 1972. It is assumed here 
that an increase in the attractiveness of 
Louisiana for practice for graduates of 
Louisiana medical schools (increase in re- 
tention rate) will also mean an increase 
in the attractiveness of Louisiana for out- 
of-state medical school graduates. The in- 
crease in attractiveness could take effect 
at different time periods in the production 
process. If the out-of-state MD graduate 
is attracted to Louisiana first for post- 
graduate training, there would be a three- 
year delay, at a minimum, before he enters 
practice in the state. Depending on this 
factor, a varying delay period before entry 
into practice could lower the 1982 estimate 
of physicians. The advantages and disad- 
vantages of various methods which in- 
crease the retention rate from 44.6 percent 
to 52.2 percent deserve further investiga- 
tion. 

Illustration C shows the increase in the 
number of medical school admissions nec- 
essary if Louisiana is to achieve the U.S. 
1971 Physician/Population Ratio by 1982 
without increasing the attractiveness of 


the state for practice (no increase in re- 
tention or attraction rates). This pro- 
posal, expansion of medical school capac- 
ity, would be extremely expensive. The 
effects of any change in admission policy 
would have an inherent time lag between 
admission and graduation from medical 
school of four years plus an average of 
three years for completion of residency. 
Thus, the final effects of an increase in 
admissions would be felt only for the last 
three years of the ten year period. It also 
would lead to an excess of physicians in 
the long run unless future demand for 
health care warrants such a large rate of 
production. 

Illustration D serves to show what the 
picture in 1982 will be if the medical 
schools in the state admit the maximum 
number of students now being considered 
and retention and attraction rates con- 
tinue as in the past. The 4,512 physicians 
for 1982 achieve the prepayment group 
estimate of need (4,479) but fall short of 
the estimate'based on the U.S. 1971 Physi- 
cian/Population Ratios (4,693). Again 
the seven year time lag between increased 
medical school admissions and the physi- 
cian specialist entering practice must be 
considered. 

Illustration E appears to be a reason- 
able compromise. To achieve 4,693 phy- 
sicians by 1982, with medical school ad- 
missions at the capacity being considered, 
Louisiana would have to increase retention 
of in-state medical school graduates from 
44.6 percent to 49.5 percent. Increased at- 
tractiveness of Louisiana for in-state med- 
ical school graduates would probably mean 
an increase in attractiveness for out-of- 
state medical school graduates for both 
residency and practice. Again, the 1982 
estimate is a maximum estimate since the 
possible three-year delay factor between 
increased attractiveness of Louisiana for 
out-of-state medical graduates and their 
entrance into active practice in the state 
is not accounted for. The long-term pro- 
duction rate of physicians would probably 
be more compatible than Illustration C 


April, 1974 — VOL. 126, No. 4 


119 


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PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


with overall growth in population and in- 
creased demand for medical care. 

Illustration F also uses the maximum 
number of medical school admissions be- 
ing considered at the present time, but has 
the U.S. 1971 Physician/Population plus 
a 20 percent increase as the 1982 goal. To 
achieve 5,632 physicians in 1982, Louisi- 
ana must retain 73.8 percent of its medical 
school graduates. (As before, depending 
on the level of training of physicians at- 
tracted from elsewhere, the 1982 estimate 
could be 50 to 100 physicians lower.) Such 
an increase in the percentage of Louisiana 
medical school graduates locating practice 
in Louisiana seems almost impossible. If 
successful, the long-range production of 
physician manpower would reach a level 
that might be considered overproduction, 
depending on other factors, ie, population 
growth. 

If we are able to meet Louisiana’s esti- 
mated future needs for physicians by such 
general measures as increasing or chang- 
ing admission policies and by developing 
programs to make Louisiana more attrac- 
tive for postgraduate training and prac- 
tice, would we have enough physicians in 
each of the major specialty areas? Using- 
data presently available, it is possible to 
get a general overview of Louisiana’s pres- 
ent status, future needs, and general ca- 
pacity for manpower production in major 
specialty areas. 

Present Status in Distribution of 
Physicians by Specialty 

It can be seen in Table 5 that the distri- 
bution of Louisiana’s medical school grad- 
uates among the major specialty group- 
ings is very similar to that found among 
those physicians who finally select Louisi- 
ana as their practice location. This is true 
in spite of the fact that Louisiana exports 
between 56 percent and 63 percent of its 
medical graduates varying according to 
specialty. (A slightly larger percentage of 
Louisiana graduates choose OB or one of 
the “other surgical specialties” than do the 
physicians who choose to practice in Lou- 
isiana.) It seems evident, therefore, that 


Louisiana has not had to import a large 
number of any given specialty as a result 
of an unusual number of the graduates of 
its medical schools being guided into other 
specialty channels, and that more Louisi- 
ana graduates have chosen each specialty 
area than are now practicing here. 

Table 6 shows how the choice of major 
specialty areas by Louisiana graduates has 
varied over the years. Although a detailed 
interpretation of this table would require 
the discussion of complex factors, it does 
illustrate the variation of choice of spe- 
cialty area over time, particularly the de- 
crease in percentage of general practition- 
ers and increase in percentage of surgical 
specialists among graduates of 1950 
through 1964. Interpretation of informa- 
tion concerning later graduates is com- 
pounded by the fact that a large number 
have not completed specialty training. 

In Table 7, the amount of variation 
found by specialty is illustrated by the rate 
change found over a five year period in 
the numbers of each type of specialist 
practicing in Louisiana.^ Most noteworthy 
is the loss of 129 family (general) practi- 
tioners, The overall increase in the num- 
ber of internists and pediatricians does 
not make up for this loss, with the number 
of primary care physicians decreasing by 
97. In both general internal medicine and 
pediatrics, the number of physicians de- 
clines through 1969. Then this trend re- 
verses and the numbers increase in 1970, 
1971, and 1972, especially in internal med- 
icine. Hopefully, this growth will con- 
tinue. Also of interest is the tremendous 
amount of growth in the other medical 
specialties particularly in the internal 
medical subspecialties — allergy, cardio- 
vascular disease, gastroenterology, and 
pulmonary diseases. 

Estimation of Louisiana’s Future Need 
by Specialty Area 

The Louisiana 1971, U.S. 1971, Prepay- 
ment Group Practice® and U.S. 1971 plus 
20 percent increase Specialty Ratios are 
applied to the projected 1982 population to 
estimate the need for specialists in Louisi- 


April, 1974— Vol. 126, No. 4 


121 


PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


ana in Table 8. Included are all active 
nonfederal physicians of all professional 
activities and excluded are interns and 
residents. Interns and residents, though 
they do render service, are omitted since 
they have not completed the physician 
manpower production process and are not 
settled in practice. In determining the 
average specialty ratio of the 4 to 6 pre- 
payment group practices, any specialty 
ratio that was totally different from all 
other ratios for that specialty was omitted 
in averaging so as to minimize distortion. 
The 20 percent increase in the U.S. 1971 
Specialty Ratios was considered as apply- 
ing to each specialty, although, in fact, one 
would expect it to be uneven, depending 
on the increased needs and demand at that 
time. 

When the number of physician special- 
ists practicing in the state as of December 
31, 1971 is compared with these estimates 
of specialist need, we can see that Louisi- 
ana is doing rather well in most areas, 
particularly the surgical specialties. Major 
needs evident were in the areas of primary 
care, mainly internal medicine, family 
practice, and, to a lesser extent, pediatrics. 
If the U.S. specialty ratios are applied, the 
specialties of anesthesiology and psychi- 
atry would need further increase. If we 
tend toward the prepayment type of prac- 
tice in the future, dermatology, and obstet- 
rics/gynecology would be the types of spe- 
cialty needed in addition to the primary 
care area. In interpreting the needs in the 
primary care area, the fact that the aver- 
age Louisiana GP is five years older on 
the average (50.3 years) than other physi- 
cian specialists (45.4 years),® and that 
there is a trend for subspecialization in 
the field of internal medicine could lead to 
underestimating the primary care needs. 

Louisiana’s Capacity to Meet Needs 
for Specialists 

In Table 9, 330 final year positions, one 
for each 1976 Louisiana graduate, are dis- 
tributed proportionately among the spe- 
cialties listed according to the U.S. 1971 
Specialist/Population Ratios and the Pre- 


payment Specialist/Population Ratios. 
This table indicates that Louisiana has 
the capacity to produce adequate numbers 
in most specialties, but in the area of pri- 
mary care our needs and our capacity for 
production are very incongruent. 

Much of this difference can be explained 
by the recent change in philosophy from 
any MD is capable of delivering high qual- 
ity primary care to the recognition that it 
requires specialty training of a special 
and unique nature to prepare a physician 
for this responsibility. (Actually many in- 
ternists and pediatricians recognized this 
years ago.) 

Discussion 

The need of an overall strategy for Lou- 
isiana’s physician manpower production 
system has been recognized by those insti- 
tutions with major interests in this area. 
To gain the kind of high financial support 
needed in this time of great change and 
rapidly increasing demand for health care, 
such a strategy becomes essential. 

The primary studies reported here gen- 
erally support similar type of information 
reported in medical literature. The major 
difference lies in our use of an oversimpli- 
fied graphic model of the production sys- 
tem in our efforts to apply this type of 
information to the physician manpower 
production system in order to delineate 
the problems specifically facing Louisiana. 

Caution must be used in the interpreta- 
tion of any data of the sort reported here 
because of the complexity of factors influ- 
encing each individual area of interest and 
the use of available data in a somewhat 
inappropriate fashion since it was not 
available in the correct form. In spite of 
these difficulties, we believe that use of 
the model gives us a greater understand- 
ing of the problems that face Louisiana’s 
health manpower production systems and 
some of the advantages and disadvantages 
of the various alternative actions that can 
be taken to modify the outputs of the sys- 
tem as we attempt to solve the problems. 
It also helps define areas where more in- 


122 


J. Louisiana State M. Soc. 


PHYSICIAN MANPOWER PLANNING — SAPPENFIELD, ET AL 


depth studies are indicated and gives some 
basis for giving priority to such studies. 

Specifically the data used to illustrate 
the model seem to indicate that Louisiana 
faces an acute shortage of physicians with- 
in ten years. General efforts to meet this 
shortage can take place at three major 
levels of training. An increase in the num- 
ber of admissions and emphasis on admis- 
sions policies that give priority to those 
who would more likely stay in Louisiana 
may be necessary. Any change at this 
level, however, has approximately seven 
years lag time before having any effect on 
the situation. Changes that would make 
Louisiana more attractive to physicians 
who have completed all of their training 
would seem more efficient and essential to 
the success of any of the programs that 
might be attempted. Since those that take 
their postgraduate training in Louisiana 
tend to stay for practice, efforts to make 
Louisiana’s postgraduate training pro- 
grams more attractive especially to our 
graduates deserve further investigation 
and support. Recent studies in this area 
will be reported separately. 

The complexity of the physician man- 
power production process and the varia- 
tions found in inputs, outputs, and needs 
according to differing specialty areas in- 
dicate that in-depth studies of such areas 
will be essential before major recommen- 
dations are made to modify the system in 
any way but a general manner. Such 
studies are planned soon when data con- 
cerning all physicians who have taken 
postgraduate training programs in Lou- 
isiana become available. 

Finally, the data presented indicate that 
the problems related to the primary care 
area deserve the highest priority when 
further studies or recommendations for 
action are considered. 

Summary and Recommendations 

In summary, this report has indicated 
that Louisiana is facing several signifi- 
cant manpower production problems in its 
preparation for the physician services it 
needs in 1982. These problems include the 


need to increase the number of physicians 
practicing in Louisiana, the need to obtain 
this increase mainly in the primary care 
areas of family practice, internal medicine 
and pediatrics and the need for an in- 
crease in attractive postgraduate training 
positions particularly in the primary care 
areas. An attempt was made to delineate 
the reasons why a statewide planning pro- 
gram is needed to face these problems. 
Finally, the report has illustrated the need 
for more specific information to be 
brought to bear on these problems before 
practical effective modification in the phy- 
sician manpower production process can 
be recommended. It is proposed that the 
committee presently involved in the pro- 
gram continue its activities in this area 
and serve as the mechanism for a coopera- 
tive program of action. The recommenda- 
tions for continuing the present planning 
activities and developing a cooperative 
program of action have been approved. 

Acknowledgement 

We wish to express appreciation to Ms. 
Gene Roback, Department of Survey Re- 
search, American Medical Association and 
also to Mr. Jim Haug, formerly of the 
same department for their time, effort and 
generous cooperation in making available 
data vital to these studies. We are also 
indebted to Mr. Jack Edwards, State Of- 
fice of Comprehensive Health Planning 
for the staff support given to the com- 
mittee. 

References 

1. Scheffler RM : The relationship between medical 

education and the statewide per capita distribution of 
physicians. J Med Education, 46:995-998, 1971 

2. JAMA, Education Number 

3. Ruhe, CHW, Thompson WV, Mixter G Jr., et al : 
Directory of Approved Internships and Residencies 1971- 
72, American Medical Association, 1971, p. 24 

4. Roback GA : Distribution of Physicians in the 

United States, 1971, Center for Health Services, Reseaixh, 
and Development. American Medical Association, Chicago, 
1972 

5. Health Manpower Perspective: 1967, Bureau of 

Health Manpower, U.S. Depai’tment of Health, Education, 
and Welfare, Washington, 1967, p. 9 

6. Bui-ford RL, Murzyn SG : Population Projections 

by Age, Race, and Sex for Louisiana and its Parishes 
1970-1985, Occasional Paper Number 10, Division of Re- 
search, College of Business Administration, LSU, Baton 
Rouge, June, 1972 


April, 1974 — Vol. 126, No. 4 


123 


PHYSICIAN MANPOWER PLANNING— SAPPENFIELD, ET AL 


7. Haug JN, Roback GA: Distribution of Physicians, 

Hospitals, and Hospital Beds in the United States, 1967, 
Department of Survey Research, AMA, Chicago, 1968. 
Haug JN, Roback GA, Theodore CN, et al : Distribution 
of Physicans, Hospitals, and Hospital Beds in the United 
States, 1968. Department of Survey Research, AMA, Chi- 
cago, 1970. Haug JN, Roback GA: Distribution of Physi- 
cians, Hospitals, and Hospital Beds in the United States, 


1969, AMA, Chicago, 1970. Haug JN, Roback CN, Martin 
BC: Distribution of Physicians in the United States, 

1970, Center for Health, Services, Research, and Develop- 
ment, AMA, Chicago, 1971. Roback GA: op. cit 

8. Mason HR: Manpower needs by specialty. JAMA, 
219:1621, No. 12, 1972 

9. Community Profiles Data Center, USPHA, from 
AMA source data, 1970 


HiBeRDia 

narionaL 


124 


J. Louisiana State M. Soc 



V parahaemolyticus Gastroenteritis: New Insight 
Into an Old Disease 

• This manuscript covers a little known organism which is gradually 
being recognized as a major source of foodborne gastroenteritis in 
this country. Since this organism is a marine saprophyte which is 
transmitted to man through improperly cooked seafood, Louisiana, 
with its tremendous seafood industry, should have a particularly keen 
interest in the organism. 

PHILIP A. MACKOWIAK, MD 
New Orleans 


'^HE earliest reliable mortality data 
available for Louisiana indicate that 
during the early days of the Louisiana 
State Board of Health, enteric diseases ac- 
counted for an estimated 598.5 deaths per 
100,000 population. These represented the 
most important source of mortality in the 
young state and were lumped together into 
three major diagnostic categories: “diar- 
rhea and dysentery,’' “Asiatic cholera,” 
and “typhoid enteritis.” Although no early 
figures are available regarding morbidity, 
it is safe to say that these enteric diseases 
(irrespective of diagnostic label) have 
been responsible for tremendous morbidity 
and mortality in Louisiana since Bien- 
ville’s first settlers found their way up 
the Lower Mississippi to found their new 
city.i 

Today the enteric diseases account for 
approximately 10 percent of all diseases 
reported to the Division of Health Main- 
tenance and Ambulatory Patient Services 
(formerly Louisiana State Department of 
Health) . These, of course, represent only 
a fraction of those cases occurring in the 
community since large numbers are never 
reported. Thanks to the evolution of the 
microbiological sciences, we can now iden- 
tify many of these diseases as to precise 
etiologic agents. Therefore, outdated de- 
scriptive categories like “dysentery” or 

Dr. Mackowiak is the Epidemic Intelligence 
Service Officer, Center for Disease Control, lo- 
cated in the Epidemiology Section, LHSRSA, Di- 
vision of Health Maintenance and Ambulatory 
Patient Services, P. O. Box 60630, New Orleans, 
La. 70160. 

Bibliography will be furnished on request. 


“cholera” have given way to definitive 
diagnoses of Shigella dysenteriae gastro- 
enteritis or Salmonella typhimurium gas- 
troenteritis, etc. Nonetheless, numerous in- 
dividual cases and bona fide outbreaks of 
gastroenteritis occur today for which we 
are unable to identify a precise etiologic 
agent. Though their number is still sub- 
stantial, little by little, investigators have 
been able to “chip away” at the category 
of “unspecified gastroenteritis” so that 
each year fewer cases evade diagnosis. 
Notable recent contributions to our under- 
standing of unspecified diarrheas have in- 
cluded identification of the Norwalk agent 
and the importance of pathogenic Escheri- 
chia coli in producing pediatric gastroen- 
teritis.--^ Isolation of the V. parahaemoly- 
ticus in Japan and subsequent isolations 
by numerous investigators in this country 
have offered yet another important contri- 
bution to our knowledge of the human 
enteridides. Since this organism is a com- 
mon contaminant of seafoods, since Lou- 
isiana consumes more seafood per capita 
each year than almost any state in the 
United States, since the largest outbreak 
of V. parahaemolyticus gastroenteritis 
ever documented took place in Louisiana 
in 1972, and since the organism is not gen- 
erally known to physicians in this coun- 
try, it seems fitting at this time to call the 
attention of Louisiana’s practitioners to 
this disease. 

Background 

V. parahaemolyticus was first isolated 
in Japan by Fujino in 1950. He originally 
isolated the organism from dried fish and 


April, 1974— Vol. 126, No. 4 


125 


GASTROENTERITIS— MACKOWIAK 


feces of individuals who had eaten this 
fish and developed “Shirasu” food poison- 
ing.^ Currently this bacterium is recog- 
nized as the etiologic agent responsible for 
70 percent of the gastroenteritis in Japan.'^ 

In 1967, B. Q. Ward, working in the In- 
stitute of Marine Sciences at the Univer- 
sity of Miami, reported isolating V. para- 
haemolyticus from frozen sediment sam- 
ples obtained from the two coasts of the 
United States.® Subsequently other Amer- 
ican investigators have confirmed its ex- 
istence in this country with isolations from 
water, sediments, crabs, oysters, shrimp, 
lobsters, and other seafoods. A report 
by Dadisman, et al,^^ last year describing 
three outbreaks of gastroenteritis in Mary- 
land related to crabs contaminated with 
the V. parahaemolyticus removed any lin- 
gering notions that V. parahaemolyticus 
gastroenteritis might be a purely Japanese 
disease. 

The Organism 

V. parahaemolyticus is a motile gram- 
negative bacillus possessing a single polar 
flagellum whose natural habitat is in estu- 
arine waters and underlying mud in most 
areas of the world. A unique feature of 
the organism as well as the reason, for its 
years of anonymity is its salt requirement. 
The organism is a halophile and as such 
will not grow on a salt-free medium. For 
this reason it will not be identified by a 
diagnostic laboratory in the course of a 
“routine stool culture.” A salt-enriched 
medium such as thiosulfate-citrate-bile 
salt-sucrose (TCBS) is needed for this. 
Under optimal conditions, the organism 
has a duplication time of ten minutes. 

Identifying biochemical characteristics 
of this organism are listed in Table 1. 

The strains of this organism are cur- 
rently classified into 10 0 antigen groups 
and 52 K antigen types. Approximately 10 
percent of strains isolated, however, are 
not typeable.^ Some of these are patho- 
genic for man while others do not appear 
to be. Pathogenic strains can be distin- 
guished from nonpathogenic ones by their 
ability to produce zones of hemolysis on a 


TABLE I 

BIOCHEMICAL CHARACTERISTICS OF 
VIBRIO PARAHAEMOLYTICUS 


(1) 

Growth in typticase broth 

REACTION 


with 0 % NoCl 

- 


with 3% NoCl 

+ 


with 7% NoCl 

+ 


with 10% NaCl 

- 

(2) 

Glucose (acid) 

+ 

(3) 

Lactose (acid) 

- 

(4) 

Sucrose (acid) 

- 

(5) 

Celloboi se (acid) 

+ 

(6) 

Maltose (acid) 

+ 

(7) 

Mannitol (acid) 

+ 

(8) 

Starch (hydroly si s) 

+ 

(9) 

Chitin digestion 

+ 

(10) 

NO3 reduction 

+ 

(11) 

Gelatin 1 i quification 

+ 

(12) 

Hugh-Leifson (anaerobic) acid only 

+ 

(13) 

Oxi dase 

+ 

(14) 

Penicillin sensitivity (2.5 u) 

+ 

(15) 

Single - polar Flagellum 

+ 

(16) 

Gram stain 

- 

(17) 

Vogues - Proskauer Rx 

- 


salt enriched blood agar (positive Kana- 
gawa reaction) . Only the Kanagawa posi- 
tive strains of V. parahaemolyticus have 
been shown to be pathogenic for man, and 
these appear to produce disease through 
production of a filterable endotoxin which 
is probably distinct from the hemolysin^® 
producing the positive Kanagawa reaction. 

V. parahaemolyticus is able to with- 
stand freezing temperatures for as long as 
six weeks when supported by a suitable 
medium (eg, shrimp meat). Small popu- 
lations of the organism in shrimp are de- 
stroyed after one minute’s exposure to a 
temperature of 60° C, whereas larger pop- 
ulations (2x10'' or greater organisms) 
may survive heating at 60-80° C for as 
long as 15 minutes. All organisms are de- 
stroyed by exposure to 100° C for one min- 
ute and are sensitive to pH values below 
6 . 0 .^® 

The Disease 

V. parahaemolyticus gastroenteritis is a 
relatively mild disease characterized by 
watery diarrhea, vomiting, and abdominal 
cramps. It occurs in man when he consumes 
contaminated seafood products which have 
been improperly cooked or recontaminated 


126 


J. Louisiana State M. Soc. 


GASTROENTERITIS— MACKOWIAK 


after cooking. The illness has an average 
incubation period of 12 to 30 hours and a 
typical duration of 24 to 48 hours. Its 
course is almost universally benign, al- 
though fluid and electrolyte imbalance re- 
sulting from the illness may pose a seri- 
ous threat to otherwise debilitated pa- 
tients. Secondary person-to-person spread 
does not appear to be an important factor 
in the epidemiology of this disease. 

Although the exact pathogenic mecha- 
nisms underlying this form of gastroen- 
teritis are not known, experimental work, 
conducted by K. Also and his colleagues, 
indicates that the disease involves local 
invasion of bowel in addition to produc- 
tion of a filterable endotoxin.^' 

The Covington Outbreak 

On August 25, 1972, a large shrimp boil 
was held in Covington, Louisiana, which 
was attended by approximately 1,200 per- 
sons. Many of the persons subsequently 
developed symptoms of acute gastroen- 
teritis. A stool specimen from one of these 
persons was referred to Dr. Oscar Felzen- 
feld, research scientist at the Delta Re- 
gional Primate Center in Covington, who 
isolated V. parahaemolyticus from the 
specimen. An intensive investigation by 
local, state and national public health rep- 
resentatives ensued. A crude attack rate 
of 51.1 percent among a representative 
cohort of persons who went to the shrimp 
boil indicated that approximately 600 of 
the 1,200 subsequently became ill. Food 
specific attack rates and later cultures of 
leftover shrimp clearly incriminated the 
shrimp as the source of infection. The 
1,600 lbs. of shrimp appeared to have been 
insufficiently cooked by a New Orleans 
seafood dealer and were then stored in an 
unrefrigerated truck for a period of 5 to 
10 hours prior to distribution. 

The epidemic curve and clinical features 
of the illness seen during this outbreak 
are illustrated in Fig 1 and Table 2. 

There were no deaths associated with 



Fig 1. 72 cases of acute gastroenteritis by 

incubation period, Covington, Louisiana, August, 
1972. 

TABLE 2 

CLINICAL FEATURES 
72 CASES ACUTE GASTROENTERITIS 
COVINGTON, LOUISIANA. AUGUST 1972 


CLINICAL 

FEATURES 


NUMBER / 
POSITIVE / TOTAL 
HISTORY/ 

PERCENT 

Nausea^ 


38/70 

54.0 

Vomiting 


25/72 

34.7 

Diorrheo 


67/72 

93.0 

Watery 


50/67 

74.5 

Bloody 


0/67 

— 

Mucous 


1/67 

1.5 

Abdominal Cramps 


49/72 

68.0 

Headache 


26/72 

36.1 

Fever - Chills 


31/72 

43.0 

’Unknown for 




2 cases 




Saw Physician 


1/72 

1.4 

Took Medicotion 
Durotion 


44/72 

61.0 

Median 

24 hours 



(Ronge) 

Incubation Period 

(2 hours - 7 days) 



Median 

23 hours 



(Range) 

(5-92 hours) 




the outbreak. Only three people are known 
to have required hospitalization as a result 
of their illnesses. 

Summary 

V. parahaemolyticus gastroenteritis is 
in all probability a very common disease. 
A conservative estimate is that it accounts 
for at least 2 percent of all foodborne out- 
breaks occurring in this country.^- In areas 
like Louisiana, where seafood is consumed 


April, 1974— Vol. 126, No. 4 


127 


GASTROENTERITIS— MACRO WIAK 


in large quantities, it must occur with sub- 
stantially higher frequency. Yet, due to the 
special growth requirements of the organ- 
ism and because of a general unawareness 
of physicians in this country of the ex- 
istence of the V. parahaemolyticus, diag- 


nosis of this disease continues to be a rare 
phenomenon. 

Acknowledgement 

I am indebted to Mr. James 0. Gettys, 
Jr., and Mrs. Ethel Hammond for assis- 
tance in preparing this manuscript. 


Keogh and You 


Who is eligible? 

B Every self-employed person engaged in business 
for himself or as a partner in a partnership. 

(Generally, a person who is subject to the Self- 
Employment Tax relating to Social Security.) 

Determining earned income 

* Earned income indudes all of the net earnings 
from trade or business even if both personal ser- 
vices and capital are material income-producing 
factors, provided the taxpayer devotes most of 
his time to the business. 


Federal Income Tax deductions 

(whether or not an Owner-Employee) 

* 100% of all contributions, including those for 

employees, subject to a maximum deduction of 
$2,500 for self-employed person's contributions 
on his own behalf. 

Maximum annual contribution for 
Owner-Employees 

■ 10% of earned income or $2,500, whichever is 
less. Fixed percentage applicable each year is 
specified in executed pension plan document. 


The Keogh plan will have the following effect on 
your Federal Income Tax: 


Without With 

Plan Plan 


$52,000 Net Earned Income $51,500 

0 Personal Retirement Plan Deduction 2,500 

52.000 Adjusted Gross Income 49,000 

9,000 Deductions and Exemptions 9,000 

43.000 Net Taxable Income 40,000 

$13,580 Federal Income Tax $12,140 


Where the future is now 



I Metropolitan Lite 

I Bob Stevens Jacques L. Couret 

I Sales Representative Sales Representative 
I 3621 Veterans Boulevard 

I Office: 888-3371 Metairie, La. 70002 

I Name: 

! Address: 

I City: 

■ State: Zip: 

I Telephone: 


128 


J. Louisiana State M. Soc. 


Pharmacogenetic Factors Affecting Drug Activity 

• "Each new drug should have its metabolic pathway elucidated 
prior to marketing. ... By attending more to pharmacogenetics, 
more specific, safer therapeutic agents will become available." 


A LTHOUGH in the United States most 
drugs available are effective and rela- 
tively safe for the majority of patients, 
the physician cannot guarantee absolute 
efficacy or absence of toxicity in a specific 
patient. The best he can do, based on pres- 
ent knowledge and accepted standards of 
current practice, is expect the chances are 
good that the patient will derive benefit 
from the treatment. The reason for this 
lack of “guaranteed results’" with drug 
therapy is our lack of understanding of 
the basic mechanisms of drug actions in 
the extremely complex and individual spe- 
cific human organism. 

Because a drug has been shown to be 
more effective than an inert placebo, even 
in multiple studies, does not mean that it 
will be effective in a given patient. There 
are very few drugs that work in virtually 
all patients in whom the drug is indicated. 
Penicillin in Group A streptococcal infec- 
tions and oral contraceptives are examples 
of drugs which are essentially 100 percent 
effective. However, most drugs are effec- 
tive in only 50 percent to 90 percent of 
the individuals for whom they are indi- 
cated. Why drugs fail to work in many 
individuals is a subject too little explored. 

A variety of genetic and environmental 
factors which influence drug delivery to 
the receptor site is gradually being eluci- 
dated. For the alert physician, these fac- 
tors help explain his occasional unexpected 
failures or adverse reactions and give him 
the opportunity, as has often been utilized 
in the past, of making significant discov- 
eries concerning drug effects in man. This 


From the Therapeutic Section, Department of 
Medicine, Tulane University School of Medicine, 
New Orleans. 


F. GILBERT McMAHON, MD 
New Orleans 

paper will review some of the genetic fac- 
tors which influence drug activity. 

One factor which makes a patient’s re- 
sponse to a drug difficult to predict is the 
genetic heterogenicity between individ- 
uals. Clinical pharmacologists often speak 
of two classes of experimental models — 
“normal subjects” and “diseased patients.” 
Excepting monozygotic twins, all patients 
differ genetically. The metabolism of 
drugs is mediated by enzymatic reactions 
which are genetically determined. Table 
1 lists some of the genetic factors impor- 

TABLE I 

SOME GENETIC FACTORS AFFECTING 
DRUG ACTIVITY 

1. Glucose-6-phosphate dehydrogenase deficiency 

2. Slow acetylators 

3. Pseudocholinesterase deficiency 

4. Glucuronyl transferase 

5. Hepatic porphyria 

6. Plasma protein abnormalities 

7. Affinity of receptor site 

8. Sex 


tant in influencing drug activity. Thirteen 
percent of America’s Negroes lack glucose- 
6-phosphate dehydrogenase, so their ery- 
throcytes are susceptible to hemolysis 
whenever a variety of stresses is imposed 
(bacterial and viral diseases, diabetic aci- 
dosis, uremia) or drugs administered (pri- 
maquine, phenacetin, p-aminosalicylic acid, 
aspirin, quinidine, probenecid, sulfa drugs, 
etc.) . 

Two other established instances of ge- 
netic polymorphism of drug metabolism 
which account for drug toxicity are acetyl- 
ation and pseudocholinesterase polymor- 
phisms which were discovered with isonia- 
zid and succinylcholine respectively. Fifty- 
two percent of American Caucasians are 


April, 1974— Vol. 126, No. 4 


133 


PHARMACOGENETIC FACTORS— McMAHON 


known to be slow-acetylators.^ The pe- 
ripheral neuropathy associated with iso- 
niazid has been shown to occur predomi- 
nantly in this group. Succinylcholine 
usually produces a short-term muscle re- 
laxation, but occasionally a patient experi- 
ences prolonged apnea due to a genetically 
abnormal plasma pseudocholinesterase. 
One wonders if the prolonged hypogly- 
cemia which occasionally occurs after sul- 
fonylurea administration might result 
from a lack of oxidation of tolbutamide or 
acetohexamide due to genetic variation. 

Glucuronyl transferase is an important 
enzyme in the metabolism of a large num- 
ber of substances, both endogenous and 
exogenous (Table 2). In addition to new- 

TABLE 2 

SUBSTANCES WHICH REQUIRE GLUCURONYL 
TRANSFERASE FOR THEIR METABOLISM 
IN MAN 


Endogenous 

Exogenous 

Estradiol 

p-aminobenzoic acid 

Estriol 

Phenolsulfonphthalein 

Andosterone 

Chloral hydrate 

Testosterone 

Morphine 

Thyroxine 

Codeine 

Pregnanediol 

Probenecid 

Bilirubin 

Indomethacin 

Tetrahydrocortisol 

Nicotinic acid 

Chloramphenicol 

Acetophenetidin 

Salicylamide 

Resorcinol 

Nalorphine 


borns, individuals with the Crigler-Najjar 
syndrome also have a genetic deficiency in 
glucuronyl transferase, so one would ex- 
pect unusual drug activity in these pa- 
tients. The parents and siblings of such 
patients, even though non-icteric often 
have diminished capacity to form glucuro- 
nides after drug administration, so these 
people must be watched for atypical drug 
responses. 

Acute intermittent (hepatic) porphyria 
is inherited as a dominant trait. Attacks 
of severe abdominal pain and other symp- 
toms can be precipitated by the ingestion 
of barbiturates, sulfonamides, griseoful- 


vin, estrogens (including the oral contra- 
ceptives), and chloroquine. 

Other genetic factors which influence 
drug activity are the plasma protein qual- 
ity and concentration. The biological ac- 
tivity of a drug is related to the unbound 
concentration in plasma. Plasma proteins 
play a critical role in the bindings and 
transport of hormones, vitamins, lipids, 
enzymes and most drugs. Genetically in- 
duced abnormalities have been described 
for 1) albumin, 2) apha- and beta-lipopro- 
teins, 3) ceruloplasmin, 4) fibrinogen, 5) 
antihemophilic globulin, and 6) gamma 
globulin. Since the quantity and quality 
of plasma proteins vary, most drugs are 
bound to them (and therefore “inactive” 
while bound) and they influence a large 
variety of hormones and other substances 
which also affect drug activity. It follows 
that the genetically determined variations 
in plasma proteins can profoundly influ- 
ence drug effect. 

Affinity of a drug for receptor sites ap- 
pears to be an inherited characteristic. 
This may account for the variable re- 
sponse among individuals receiving cou- 
marin drugs. Dextro thyroxine, clofibrate 
and norethandrolone potentiate the anti- 
coagulant effect of coumarin drugs, with- 
out affecting the absorption, excretion or 
binding of the anticoagulant. It is felt that 
they act by influencing receptor site af- 
finity. 

Although sexual differences in drug re- 
sponses are well known in animals, few 
studies have been done in man. Amino- 
pyrine, phenylbutazone, and chlorproma- 
zine agranuloc 3 d;osis occur more frequently 
in females than in males. Chlorampheni- 
col-induced pancytopenia is also more com- 
mon in females. Clofibrate appears to be 
more effective in reducing lipid levels in 
females than in males. 

An interesting study of “five blue sol- 
diers” was recently reported by Cohen, et 
al.“ Four cyanotic American soldiers and 
one healthy identical twin were hospital- 
ized in Vietnam. Each had been receiving 
prophylactic doses of chloroquine, pri- 


134 


J. Louisiana State M. Soc. 


PHARMACOGENETIC FACTORS— McMAHON 


maquine and diaminodiphenyl sulfone 
(DDS). Deficient levels of the enzyme 
methemoglobin reductase were demon- 
strated in each of these men. Studies in 19 
family members suggested that the en- 
zyme deficiency is inherited as an auto- 
somal recessive trait. It was further shown 
that the usual prophylactic doses of each 
of these antimalarial drugs could produce 
symptomatic methemoglobinemia. 

Conclusion 

In conclusion, the study of drugs in man 
requires that serious attention be given 
genetic factors. Each new drug should 


have its metabolic pathway elucidated 
prior to marketing. Potential for inducing 
hemolysis in glucose-6-phosphate deficient 
patients should be ascertained. If a new 
drug requires glucuronyl transferase in its 
metabolism, it should be contraindicated 
in the newborn. By attending more to 
pharmacogenetics, more specific, safer 
therapeutic agents will become available. 

References 

1. Knight RA, Selin MJ, Harris HW : Genetic factors 
influencing isoniazid blood levels in humans. Trans, of 
the 18th Conf. on the Chemotherapy of Tuberculosis pp. 
52-58 (Feb) 1959 

2. Cohen RJ, Sachs JR, Wicker DJ, et al: Five blue 

soldiers : Methemoglobinemia provoked by antimalarial 

chemoprophylaxis. Clin Res 16:301 (April) 1968 


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April, 1974— Vol. 126, No. 4 


135 




IN A NUT SHELL... 

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136 


J. Louisiana State M. Soc. 


-S 


ocioeconomic 



By LEON M. LANGLEY, JR. 


The LSMS Will Present a Special Louisiana PSRO Update. The “Update” will be in 
connection with the DOCTOR TO DOCTOR Program on the Louisiana Hospital 
T.V. Network on April 18, from 7 :00 p.m. to 9:00 p.m. The program will fea- 
ture James H. Sammons, MD, Chairman of the AMA Board of Trustees; James 
H. Stewart, MD, LSMS President; and two practicing Louisiana physicians with 
divergent views on PSRO. LSMS members may utilize the two-way talk back sys- 
tem on the Hospital Television Network to ask questions of the panelists. 

In 1972 Patient Visits to Private Practitioners for Treatment of Alcoholism 

amounted to slightly more than three million visits, reports the National Dis- 
ease and Therapeutic Index (NDTI). Of these visits, 37% were made to gen- 
eral practitioners, 29% to psychiatrists, and 25% to internists. Male patients 
accounted for two-thirds of all the visits. As for the ages of the patients, 60% 
were in the 40-59 bracket; 20% were between 20 and 39 years old; and the 
remaining 20% were 60 and over. The NDTI report confirms that alcoholism 
is a chronic disease and that only one out of every five visits represents a pa- 
tient’s first contact with the physician for alcoholism. 

Federal Spending for Health in the next fiscal year, as proposed February 4 in the 
President’s Budget Message to Congress, will be $35.5 billion. That is 11% of 
the total budget of $304.4 billion. The budget calls for spending $26 billion in 
fiscal 1975 for HEW health program, an increase of $3 billion largely due to 
rising costs of Medicare and Medicaid. Federal spending for Medicaid is put 
at $6.5 billion, an increase of $700 million, and for Medicare $14.2 billion, an 
increase of $2 billion. The budget contains no figure for NHI, but the Admin- 
istration’s plan is expected to cost about $5.8 billion. Health maintenance 
organizations (contract practice) would get $30 million in the current fiscal 
year and $45 million in fiscal 1975, as well as $50 million for a direct loan 
fund. Professional standards review organizations would get $34 million in 
fiscal 1975. 

Chances Are Steadily Increasing that a physician’s next nurse will be male rather than 
female. The percentage of males in nursing graduating classes has nearly dou- 
bled since 1970 and is expected to rise even further, shows a survey by the mag- 
azine RN. In 1970, 2.6% of the 33,679 nurses graduated were men; in 1973, 
the percentage had risen to 4.5% of a graduating class of 50,742. Next year’s 
crop is expected to be 6.2% or 3,741 men in a class of 60,168 graduates. Of 
these recent graduates, 38% are veterans. The greatest number of men were 
graduated by the University of Texas — 36 out of a class of 316. 

The First Survey of Work-Related Injuries and illnesses under the Occupational 
Health and Safety Act, a new federal safety law, showed that one out of every 
ten workers suffered an occupational injury or sickness in 1972. The Labor De- 
partment said the construction industry had the highest rate of any major cate- 
gory, with 19 of every 100 workers suffering an occupational injury or illness. 
Manufacturing was next with 15.5 out of every 100. 

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April, 1974 — Vol. 126, No. 4 


137 


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138 


J. Louisiana State M. Soc. 






(^ditoriui 


Statewide Physician Manpower Planning 
in Louisiana 


This issue of the Journal contains the 
first of several papers which report State- 
wide Physician Manpower Planning in 
Louisiana. This initial paper is subti- 
tled, “Basis for Planning and Primary 
Studies”. Subsequent papers are subti- 
tled, “Investigation of Stated Reasons 
Why Physician Trainees Leave or Stay 
in Louisiana”, and “Estimated Needs for 
Primary Care Physicians”. 

A new study by MAS Institute of 
Medicine identifies the gross cost of a 
year in medical school to be $12,650 for 
each student. 

The information contained in the three 
above mentioned papers should prove use- 
ful to several groups. 

The State Legislature can use accu- 
rate information relative to the educa- 
tion of physicians so that the legislature 
might make more informed decisions in 
allotting state resources to medical edu- 
cation. 

Individual communities, which are suf- 
fering from physican shortage, will be 


JOSEPH A. SABATIER, JR., MD 
New Orleans 

in a better position to assess their own 
attractiveness to these physicians and to 
modify their approach to effective recruit- 
ment of such individuals. 

The medical schools might utilize this 
information in modifying their own cur- 
ricula principally as applied to the pro- 
duction of various specialty representa- 
tives, so that their productivity might 
more closely approximate the needs of the 
area. 

Medical students might find this infor- 
mation useful in their decisions relating 
to career choices as well as their deci- 
sions relating to ultimate site of location 
for practice. 

Each physician in the state is urged 
to review the information presented in 
these studies and to offer comments in a 
constructive way so that the citizens of 
the state as a whole might continue to 
profit from increasing efficiency and ef- 
fectiveness of medical education and phy- 
sician distribution. 



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April, 1974 — Vol. 126, No. 4 


139 




C^rt^ anlz aiion Section 


The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 



JAMES H. STEWART, MD 
President 
1973-1974 


Dr. James H. Stewart, our president, 
is nearing one year of leadership to the 
Louisiana State Medical Society, a year 
that will stand out prominently in the 
history of the Society. 

With the battle concerning PSRO 
(professional standards review organiza- 
tion) reaching its peak. Dr. Stewart has 
represented the Society most admirably 
in expressing the policy of our organiza- 
tion in opposition to the onerous Bennett 
amendment. Several of these presenta- 
tions were at regional HEW meetings 
for geographical designations of PSRO 
in which he argued that the State of 


Louisiana not be divided into multiple 
PSRO’s. Four areas have since been 
designated for Louisiana but there has 
been continued protest ever since from 
our group. 

National Health Insurance is on the 
horizon and some Congressmen and po- 
litical experts feel that several bills will 
be introduced before 1975. No partic- 
ular Bill, Medicredit, Kennedy or Ad- 
ministration seems to have the full ac- 
cord of the Congress, but some parts of 
all seem to be likely. Our Congressional 
delegation knows and will continue to 
know our views. 

Health Maintenance Organizations 
have passed the Congress. Dr. Stewart 
has worked tirelessly to keep this gov- 
ernment subsidized form of health care 
from taking over in this State and thus 
far has been successful even though this 
form of legislation had advanced con- 
siderably prior to his term of office. 

Dr. Stewart has demonstrated much 
diligence on many occasions with his 
prompt and forceful responses to irre- 
sponsible newspaper and media releases 
and to many regulatory documents pre- 
viously put out by HEW referable to 
health care. Louisiana is one of the few 
States that received equal time on C.B.S. 
to rebut the onerous show “What Price 
Health.” Dr. Stewart, along with Dr. 
Eugene St. Martin, Dr. Mike Smith, and 
Dr. Conway Magee appeared on T.V. in 
New Orleans and rebutted the accusa- 
tions most effectively. A tape was made 
of this that was to be shown in and out 
of the State. After a showing in Shreve- 
port it was mysteriously lost. Probably 
another “Watergate” with the media be- 
ing the offender. 

He has done considerable visitation 


140 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


around the State among component so- 
cieties trying to personally keep them in- 
formed about the dangers confronting 
the Profession as well as how to cope 
with same. He has been well received in 
all instances and has done much to ce- 
ment the Louisiana State Medical So- 
ciety into a solid unit working diligently 
with togetherness which surpassed all 
previous efforts. 

For one so busy as Dr. Stewart, he has 
been most available and helpful to the 
staff in responding to the controversial 
schemes constantly confronting the Pro- 
fession. His duties as president have 
taken him away from the city and his 
practice on numerous occasions in our 
behalf, always bringing credit to our 
organization by super public relations. 
Having Louise along on many occasions 
was also an asset to our delegations. 

Dr. Stewart has been able to accom- 
plish what he has because he has demon- 
strated a liking for and an immense 
capability of leadership, having served 
on the Council of the LSMS for several 
years as representative of the First Con- 
gressional District, third vice-president, 
first vice-president, and president-elect 
before he was installed as president on 
May 1, 1973. Prior to that he had served 
for six years on the Board of Directors 
of the Orleans Parish Medical Society 
and two years as president of the medi- 
cal staff of Sara Mayo Hospital. 

It would seem as though good fortune 
played a part in the history of LSMS for 
Jim to ascend to the presidency at the 
time he was called. It is also fitting that 
we would be blessed with a leader that 
came up the so-called “hard way.” 

Jim was born a relatively poor boy in 
Ligon (Floyd County), Kentucky on 
May 25, 1926. He is the son of a coal 
miner, attended the local public school, 
then a county high school. Wheelwright 
High, ten miles away. Apparently there 
was no energy crisis at the time, other- 
wise things might have been different 
for us as well as for Jim and his family. 


He won a scholarship which allowed him 
to attend Caney Junior College (now 
Alice Lloyd College) in Pippa Passes, 
Kentucky. From there he won additional 
scholarship grants which allowed him to 
go on to the University of Kentucky to 
earn his BS degree and to Tulane Uni- 
versity School of Medicine for his MD 
degree. Young Stewart was determined 
not to be just another coal miner, and 
by the educational routes mentioned, he 
was graduated from medical school at 
age 20, a record or close to it, at Tulane 
for this century. 

Dr. Stewart’s postgraduate career has 
been very diversified, reading like Who’s 
Who ? His internship was followed by 
training in pathology, then general sur- 
gery at Touro Infirmary. His surgical 
residency was interrupted by the Korean 
war but he was able to complete same in 
1953. He subsequently trained in cardio- 
vascular and thoracic surgery while in 
naval service at the U. S. Naval Hospital 
in Norfolk, Virginia. He resigned his 
commission in 1958 and since that time 
has been in private practice of general, 
cardiovascular and thoracic surgery in 
New Orleans. He is on the medical staff 
of many hospitals in Orleans and Jeffer- 
son Parishes and is on the part-time fac- 
ulty of the Department of Surgery at 
Tulane, with the rank of Associate Pro- 
fessor. 

This phenomenal man, in addition to 
authorship of several scientific articles, 
has to his professional credit the design 
and construction of the first cardiac de- 
fibrillator in New Orleans as well as de- 
sign and construction of the first transis- 
torized cardiac pacemaker used in New 
Orleans. 

Dr. Stewart was a navy man for ten 
years, attaining the rank of Commander. 
Combat service with the Marine Division 
in Korea (1950-51) would fill a book in 
itself. Needless to say he was decorated 
for this part of his service, the Bronze 
Star with the Combat “V” being his 
award. 


April, 1974— Vol. 126, No. 4 


141 


ORGANIZATION SECTION 


A powerful lot of people 
have been saving at 
Eureka since 1 884 



2525 Canal Street Phone 822-0650 
110 Belle Chasse Hwy. 

West Bank Division 
EUREKA HOMESTEAD SOCIETY 


Jim is a man of many and varied hob- 
bies. His continuing interest in elec- 
tronics culminated in his becoming an 
Electronics Engineer, with a First Class 
License from the FCC. He enjoyed a 
number of years’ activity in amateur ra- 
dio, having designed and constructed a 
600 watt transmitter, employing a unique 
system of cathode modulation. He now 
serves as Consultant to two New Orleans 
based electronics firms. 

Growing out of this came an interest 
in computer design and technology. He 
completed two intensive courses in Com- 
puter Science at Tulane and has subse- 
quently participated in computer sys- 
tems design. He has written progi'ams in 
several computer languages, including 
programs for all his office business ac- 
tivity. 

In 1944 he was bitten by the aviation 
bug, the J-3 Cubs and the Aeronca 
Champs got him. He was able to pur- 
chase flying time by marketing his 
blood. H^ earned a Commercial license 
and later became a Flight Instructor and 
Instrument Instructor. He is certified in 
single and multi-engine land planes and 
single engine seaplanes. He now serves 
on the Advisory Board for the Lakefront 
Airport. 

Growing up in the hills, Jim acquired 
a love for country music. He was self 
taught and learned to play by ear. He 
helped himself through college playing 
the fiddle at dances and on radio. He 
learned to play the Hawaiian steel gui- 
tar and played on the Saturday night 
“Dixie Barn Dance,” New Orleans’ ver- 
sion of the Grand Ole Opry. As his med- 
ical practice demanded more and more 
of his time and energy, this musical tal- 
ent took a back seat. He sneaks out 
incognito at times and joins the groups 
and each fall journeys to Nashville for 
the annual country music convention. 

Other hobbies include photography, 
chess (he lost to Bobby Fischer), math 
games, hunting and fishing. 

J. Louisiana State M. Soc. 



ORGANIZATION SECTION 


Jim is married to the former Louise 
Johnson of Miami, Florida. Their four 
children are James, Jr., Virginia, Cyn- 
thia and Allan. Recently Louise and the 
children have not seen as much of their 
Dad as has been their custom but before 
long Jim’s presidential duties will have 
terminated and the family circle re- 
united. We are grateful to Louise and 
the children for their willingness in shar- 
ing Jim during the past year. 

Our Louisiana State Medical Society is 
deeply indebted to Louise and Jim for 
their untiring efforts and guidance in 
our behalf during another strenuous 
year. Jim’s war efforts have proven very 
beneficial to us as exemplified by his 
constant alertness and watchfulness over 
all forces that could be detrimental. Our 
commendations go out to our leader and 
it is hoped that after May 1974 he will 
not retire to the category of “ex’s” and 
continue to share his tremendous ability 
and know-how which he has demon- 
strated so convincingly the past year. 

Well done, Jim. You may take your 
bow with the utmost of pride. 


SPECIAL FORMS FOR REPORTING 
BIRTHS AND DEATHS FROM ABORTIONS 

The State Registrar of Vital Statistics advises 
that all hospitals in the State have been forward- 
ed specially prepared forms for use in reporting 
live births, fetal and infant deaths, as a result 
of abortions. These forms were prepared in ac- 
cordance with the provisions of Act No. 75 of 
1973 and the said Act makes it mandatory for 
all attending physicians -to report these events on 
the special proper forms, and also provides for a 
penalty of a fine or imprisonment or both for 
failure to do so, within 15 days after the abortion 
is performed as required by the Act. 

The form entitled “Live Birth by Abortion” is 
to be used for all live born fetuses regardless of 
the gestational period. The form headed “Fetal 
Death or Infant Death by Abortion” is to be 
employed when a fetus is delivered stillborn re- 
gardless of gestational period and the same form 
is to be used when a fetus is live bom by reason 
of abortion and dies shortly thereafter. The stan- 
dard definitions for live birth, infant death and 
fetal death still apply in these cases except for 
the reporting at any period of gestation as de- 
fined in the Act. 


In order that the data on these events do not 
conflict with our usual ordinary vital statistics 
tabulations, all events occurring as a result of 
abortion will be compiled separately and not 
necessarily be contained in our regular natality 
and mortality statistical reports. 

Additional forms may be requested from the 
State Registrar of Vital Statistics at Post Office 
Box 60630, New Orleans, Louisiana 70160 and 
all reports on the above events including those 
from Orleans Parish, must be forwarded directly 
to the State Registrar of Vital Statistics. 


CHIROPRACTIC ENDANGERS QUALITY 
HEALTH CARE 

Inclusion of chiropractic under the Medicare 
law, places “in jeopardy the integrity of the 
entire Medicare - Medicaid program” and poses 
a “threat” to quality health care for the people, 
an official of the American Medical Association 
said in Jacksonville, Florida, recently. 

H. Thomas Ballantine, MD, Boston neurosur- 
geon and chairman of AMA’s Committee on 
Quackery, also called attention to a little known 
provision in the U.S. Department of Health, Edu- 
cation and Welfare appropriations bill adopted 
recently by the 93rd Congress that budgets for 
the National Institute of Neurological Diseases 


ANNOUNCEMENT 


A Residency in Physical Medicine and 
Rehabilitation at Charity Hospital in New 
Orleans, La., has recently been approved 
by the Council on Graduate Education of 
the American Medical Association. 

This is a Three-Year Program 

Substitutions Allow^ed: 

1. 1st year substitutes for an intern- 
ship. 

2. 1 year formal credit for four years 
or more of General Practice. 

3. 1 year formal credit for residency 
training in another specialty. 


If Interested, Please Contact 
DOCTOR LARRY McKINSTRY 

Room 320, LM Building 
Charity Hospital 
1532 Tulane Avenue 

New Orleans, Louisiana Telephone: 527-8431 


April, 1974 — Vol. 126, No. 4 


143 


ORGANIZATION SECTION 


and Stroke “as much as $2,000,000” for an “in- 
dependent, unbiased” study of the fundamentals 
of chiropractic. The HEW appropriations bill 
was signed by the President in December. 

Dr. Ballantine spoke at the luncheon meeting 
of the Southeast Regional Conference on Health 
Quackery-Chiropractic, sponsored by the AMA 
Committee. 

In commenting on chiropractic’s inclusion un- 
der Medicare, Dr. Ballantine said: 

“Probably at no time in the nine years since 
the Medicare program was enacted has there been 
what we consider a more serious threat than this 
to the high quality care called for in the Medi- 
care legislation.” 

The proposed standard for chiropractor eligi- 
bility to participate in Medicare, which Dr. Bal- 
lantine called the “minimum” possible under the 
law, “will in effect guide patients to point-of- 
entry health care providers (chiropractors) whose 
methods of diagnosis and treatment are lacking 
in scientific validity.” 

Dr. Ballantine posed a series of questions that 
he said “need to be answered by those who are 


called upon to administer the chiropractic provi- 
sions” added to the Medicare law before the 
standards and regulations are finalized. Among 
them: 

“Should not the minimum standard for chiro- 
practic participation require, at the very least, 
that chiropractors be graduates of schools ac- 
credited by a nationally recognized educational 
accrediting agency? 

“What is a subluxation, (a maladjustment of 
the spine) as that term is used to define chiro- 
practic services? 

“What are the diagnostic standards by which a 
subluxation shall be deemed to have been shown 
by current x-ray techniques? 

“What pathological conditions of the human 
body are brought about by a so-called subluxa- 
tion? 

“What evidence is there that manual manipu- 
lation of the spine can correct a so-called sub- 
luxation and thereby influence favorably a dis- 
ease process? 

“What is a neuromusculoskeletal condition, as 
intended in the published regulations, and who is 


At Your Service in 
The Pelican State 


In the region* named by LaSalle 
in honor of Louis XIV and 
sometimes called The Creole 
State because of its many 
descendants of early French and 
Spanish settlers . . . 


PHARMACEUTICAL DIVISION 

MARION 

LABORATORIES. INC. 

KANSAS CITY, MO. ^4137 

is represented by . . . 




144 


J. Louisiana State M. Soc. 


ORGANIZATIOJS SECTION 


to determine that manual manipulation of the 
spine is the appropriate treatment?” 

And, finally, Dr. Ballantine posed the question 
whether chiropractic qualifies at all under the 
section of the Medicare law that prohibits pay- 
ments for items and seiwices “which are not rea- 
sonable and necessary for the diagnosis or treat- 
ment of illness or injury or to improve the func- 
tion of a malformed body member.” 

Dr. Ballantine said the standards and regula- 
tions, as finalized by HEW and the Social Se- 
curity Administration, are expected to be an- 
nounced within the next month. 


“TODAY’S HEALTH” TO BE A NEW 
WEEKLY TV PROGRAM 

The American Medical Association and Stan- 
dard Brands, Inc. jointly announced recently a 
new television series titled “Today’s Health.” 
The series is being produced by Gittelman Film 
Associates in association with the AMA consuiner 
magazine of the same name. This syndicated 
weekly half-hour series is designed to explore 
varied aspects of health and medicine. Material 


from the AMA magazine will be utilized ; AMA 
experts and editors will act as consultants. 

“Today’s Health” will be co-hosted by Norman 
Pastorek, MD, who teaches at the New York Hos- 
pital-Cornell Medical Center and is in practice in 
New Rochelle, N.Y., and Ms. Carlin Glynn, 
actress, mother of three, and an active partici- 
pant in a consumer action group, “Consumer 
Action Now,” has appeared on TV and talk shows 
in U.S. and Canada on behalf of CAN. 

Each half-hour will be done in three segments. 
The first will provide information and up-to-the- 
minute developments in health and medicine. The 
second segment, filmed on location, will involve 
nationally known figures and their stories in the 
combatting of personal health problems. For ex- 
ample, in the first show Peter Sellers will discuss 
how he has coped with a coronary attack that 
almost killed him, and how he has pursued an 
active career following his illness. 

Future guests will include other well-known 
celebrities discussing their own personal health 
problems. 

The third segment can best be described as an 



Puts comfort 
in your prescription 
for nicotinic acid 


April, 1974 — Vol. 126, No. 4 


145 


ORGANIZATION SECTION 


informal dialogue involving health authorities on 
provocative subjects which would encompass ma- 
terial the viewers might rather not hear about 
themselves, but really want to know. 

The “Today’s Health” series is a part of a 
continuing effort by Standard Brands, Inc. to 
impart sound nutritional and medical information 
to the American people, and is primarily spon- 
sored on behalf of Fleischmann’s 100% corn oil 
margarine, and Egg Beaters, the new cholesterol- 
free egg substitute. 

Philip Gittelman, president and executive pro- 
ducer of GFA, was formerly the producer for 
CBS news involved in the development and pro- 
duction of the award-winning Hidden Revolution 
series hosted by the late Ed Murrow. Other series 
written and produced by Gittelman were New 
Portrait with Charles Collingwood, Close Up 
with Mike Wallace, as well as various public af- 
fairs documentaries. 

“Today’s Health” is being distributed through 
television stations on a trade basis beginning 
April 1974 by Ted Bates Advertising, Inc. Ac- 
cording to Joel Segal, Senior Vice President, Net- 
work and Syndication Division of the Media Pro- 
grams Department, “We have already had sig- 
nificant expressions of interest from stations for 
a series of this nature involving meaningful in- 
formation presented in an entertaining fashion.” 

It is hoped that 60-100 TV stations will sched- 
ule “Today’s Health” with an estimated audience 
of seven million. 


Physician Wanted 

WONDERFUL OPPORTUNITY for physi- 
cian in private practice of medicine. Chief 
of Emergency Medical Services Department 
seeing 18,000 patients per year. 200-|- bed 
hospital in beautiful semi-resort city on 
fast growing LA Gulf Coast. Fee for ser- 
vice, with initial guarantee. For immediate 
reply, send resume to Stephen B. Collins, 
Executive Director, or Dr. Avery L. Cook, 
President, Medical Staff, Lake Charles Me- 
morial Hospital, P. O. Box M, Lake Charles, 
LA 70601, or call collect (318) 478-1310. 


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VETERANS & CAUSEWAY 

"The dealership that's different': 


146 


J. Louisiana State M. Soc. 




CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every nnonth 


Calcasieu 

Fourth Tuesday ot every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday of every month 

Baton Rouge 

Jackson-Lincoln-Union 

Third Tuesday of every month 
except summer months 

Jefferson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every other month 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

Independence 

Terrebonne 

Third Monday of every month 

Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday ot every month 



20th ANNUAL SOUTHERN OB-GYN 
SEMINAR 
JULY 21-26, 1974 

The 20th Annual Ob-Gyn Seminar will be held 
again this year in Asheville, North Carolina at the 
Grove Park Inn, July 21 through July 26. 

A wide variety of subjects in obstetrics and 
gynecology will be presented and program par- 
ticipation \\ull include the medical schools of 
North Carolina, Duke, Bowman Gray and the 
Medical College of Virginia, in addition to out- 
standing speakers from other areas. 

For registration information, please contact 
the Secretary, Dr. George T. Schneider, 1514 
Jefferson Highway, New Orleans, Louisiana 
70121. 


JOBS (HIS AND HERS) . . . WHICH IS 
WHOSE? ONLY YOUR GOVERNMENT 
KNOWS FOR SURE 

“It is not realistic to expect that women will 
apply for job openings advertised for foremen, 
salesmen or credit men,” says Carmen R. Maymi. 

“Nor will men apply for job vacancies calling 
for laundresses, maids, or airline stewardesses.” 

Her solution: Change any job titles that con- 
tain “sex stereotypes.” In fact, she has announced 
that the government’s Occupational Classifica- 
tions System has just changed no fewer than 52 
sex-stereotyped job titles. 

No longer will those burly guys who run the 
newspaper presses be known as pressmen. From 
now on, they’re printing press operators. 


Longshoremen are now longshore workers. 

Busboys have become waiters’ assistants. (But, 
please note, “waiter” is a sex-stereotyped job 
title, too.) 

Chambermaids and maids in hotels and motels 
are retitled lodging quarters cleaners, while their 
counterparts who work in private homes are now 
— guess what — private household cleaners ! 

Boatmen and canalmen have become boat oper- 
ators. (Tugboat Annie would have detested that.) 

And fishermen and oystermen are now called 
fishers, hunters and trappers. (Hunters and trap- 
pers? Yes, that’s what the press handout says.) 

One sex stereotype Ms. Maymi, et al, haven’t 
changed: the name of her own organization. At 
the Department of Labor, she’s director of the 
Women’s Bureau. 


SYMPOSIUM ON NON-NARCOTIC 
DRUG ABUSE 

A general overview of the treatment of non- 
narcotic multiple drug abuse is to be presented 
in Houston, May 20-23, 1974. Emphasizing clin- 
ical ser\uces for the poly-drug abuser, the sympo- 
sium is designed for health care delivery profes- 
sionals and paraprofessionals. The first three 
days. May 20-22, emphasize the drugs that are 
abused, the patients who abuse them, and treat- 
ment techniques in current use. The fourth day. 
May 23, provides workshops for small groups in 
diagnostic and treatment techniques and pharma- 
cology of tolerance and addiction. 


April, 1974— Vol. 126, No. 4 


147 





euiew 


Psychiatry and Law; by Ralph Slovenko, LLB, 

PhD, Little, Brown and Company, Boston, 726 

pp, 1973, $28.50. 

Professor Ralph Slovenko, a former faculty 
member of Tulane University’s School of Law 
and presently professor of law and psychiatry at 
Wayne State University’s School of Law, has 
unique qualifications to have developed this com- 
pendium on psychiatry and law. In addition to 
having his LLB he took a three-year residency 
in psychiatry, together with physicians, at Tu- 
lane Medical School and subsequently spent two 
years on the staff of the famed Menninger Clinic. 
Slovenko’s writings in the field of forensic psy- 
chiatry have been prolific, and he has maintained 
an easily readable style which incorporates 
learned opinions with themes from popular cul- 
ture. 

This present volume can serve as a basic ref- 
erence source for psychiatrists and for physi- 
cians who are occasionally confronted with prob- 
lems involving law and mental illness. The psy- 
chiatrist will find this to be a valuable reference 
source with a critical exposition of many of the 
interworkings of psychiatry and law. The non- 
psychiatric physician can increase his under- 
standing of areas such as family law involving 
divorce, child custody and abortion; he would do 
well to increase his knowledge of neurosis asso- 
ciated with trauma; with an increasing aging 
population, he will find much of value in the 
chapter dealing with the criteria necessary to 
make a valid will. Among other interesting and 
pertinent chapters are those on alcoholism, drug 
addiction and privileged communication. 

Professor Slovenko provides an author, case 
and subject index, but in addition there is an 
invaluable 76-page section of selected readings 
for those who want to go deeper into any partic- 
ular area. However, again what is attractive 
about this book is the light, interesting style in 
which the author approaches the issues of psy- 
chiatry and law. 

Gene Usdin, MD 


ANNUAL MEETING 

Louisiana State Medical 
Society 

May 5, 6, 1 . 1974 
LAKE CHARLES 


Rondomycin 

(methacycline HCI) 


CONTRAINDICATIONS: Hypersensitivity to any of the tetracyciines. 

WARNINGS: Tetracycline usage during tooth development (last half of pregnancy to eight 
years) may cause permanent tooth discoloration (yellow-gray-brown), which is more 
common during long-term use but has occurred after repeated short-term courses. 
Enamel hypoplasia has also been reported. Tetracyclines should not be used in this age 
group unless other drugs are not likely to be effective or are contraindicated. 
Usage in pregnancy. (See above WARNINGS about use during tooth development.) 

Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de- 
veloping fetus (often related to retardation of skeletal development). Embryotoxicity has 
also been noted in animals treated early in pregnancy. 

Usage in newborns, infants, and children. (See above WARNINGS about use during 
tooth development.) 

All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease 
in fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6 
hours was reversible when drug was discontinued. 

Tetracyclines are present in milk of lactating women taking tetracyclines. 

To avoid excess systemic accumulation and liver toxicity in patients with impaired renal 
function, reduce usual total dosage and, if therapy is prolonged, consider serum level de- 
terminations of drug. The anti-anabolic action of tetracyclines may increase BUN. While 
not a problem in normal renal function, in patients with significantly impaired function, 
higher-tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis. 

Photosensitivity manifested by exaggerated sunburn reaction has occurred with tetra- 
cyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be so ad- 
vised, and treatment should be discontinued at first evidence of skin erythema. 
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible organisms, 
including fungi, discontinue antibiotic and.start appropriate therapy. 

In venereal disease, when coexistent syphilis is suspected, perform darkfield exami- 
nation before therapy, and serologically test for syphilis monthly for at least four months. 

Tetracyclines have been shown to depress plasma prothrombin activity; patients on an- 
ticoagulant therapy may require downward adjustment of their anticoagulant dosage. 

In long-term therapy, perform periodic organ system evaluations (including blood, 
renal, hepatic). 

Treat all G roup A beta-hemolytic streptococcal infections for at least 10 days. 

Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, avoid 
giving tetracycline with penicillin. 

ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms); anorexia, nausea, 
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with monil- 
ial overgrowth) in the anogenital region. 

Skin: maculopapular and erythematous rashes; exfoliative dermatitis (uncommon). Pho- 
tosensitivity is discussed above (See WARNINGS). 

Renal toxicity: rise in BUN, apparently dose related (See WARNINGS). 

Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura, 
pericarditis, exacerbation of systemic lupus erythematosus. 

Bulging fontanels, reported in young infants after full therapeutic dosage, have disap- 
peared rapidly when drug was discontinued. 

Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia. 

Over prolonged periods, tetracyclines have been reported to produce brown-black mi- 
croscopic discoloration of thyroid glands; no abnormalities of thyroid function studies are 
known to occur. 

USUAL DOSAGE: Adults- 600 mg daily, divided into two or four equally spaced doses. 
More severe infections: an initial dose of 300 mg followed by 150 mg every six hours or 
300 mg every 12 hours. Gonorrhea: In uncomplicated gonorrhea, when penicillin is con- 
traindicated, 'Rondomycin' (methacycline HCI) may be used for treating both males and 
females in the following clinical dosage schedule; 900 mg initially, followed by 300 mg 
q.i.d. for a total of 5.4 grams. 

Fortreatment of syphilis, when penicillin is contraindicated, a total of 18 to 24 grams of 
'Rondomycin' (methacycline HCI) in equally divided doses over a period of 10-15 days 
should be given. Close follow-up, including laboratory tests, is recommended. 

Eaton Agent pneumonia: 900 mg daily for six days. 

Children -3 to 6 mg/lb/day divided into two tofour equally spaced doses. 

Therapy should be continued for at least 24-48 hours after symptoms and fever have 
subsided. 

Concomitant therapy; Antacids containing aluminum, calcium or magnesium impair ab- 
sorption and are contraindicated. Food and some dairy products also interfere. Give drug 
one hour before or two hours after meals. Pediatric oral dosage forms should not be 
given with milk formulas and should be given at least one hour prior to feeding. 

In patients with renal impairment (see WARNINGS), total dosage should be decreased 
by reducing recommended individual doses or by extending time intervals between 
doses. 

In streptococcal infections, a therapeutic dose should be given for at least 10 days. 
SUPPLIED: 'Rondomycin' (methacycline HCI); 150 mg and 300 mg capsules; syrup con- 
taining 75 mg/5 cc methacycline HCI. 

Before prescribing, consult package circular or latest PDR information. 

Rev. 6/73 

kffi WALLACE PHARMACEUTICALS 
CRANBURY, NEW JERSEY 08512 


148 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


$6.00 Per Annum, $1.00 Per Copy TV/TAV 1 Q7A Published Monthly 

Vol. 126, No. 5 1VJ.2A X , XV I ‘± 1700 Josephine Street, New Orleans, La. 70113 


Early Diagnosis of the Zollinger-Ellison Syndrome 

• "Early diagnosis is possible by considering every patient with 
peptic ulceration as a potential ZE syndrome. The available diag- 
nostic tests are discussed, and a patient with a microadenoma and 
islet hyperplasia is presented demonstrating early diagnosis utilizing 
gastric analysis and pancreatic tail biopsy." 

DONALD J. PALMISANO, MD 
JAMES E. BROWN, MD 
New Orleans 


^OLLINGER and Ellison described in 
^ 1955 non-insulin producing islet cell 
tumors of the pancreas associated with in- 
creased gastric secretion and marked pep- 
tic ulcer symptoms.^ It is now a well rec- 
ognized entity with over 1,000 cases re- 
ported to date.^ Unfortunately, many of 
the cases have been diagnosed only after 
multiple complications and inadequate sur- 
gical procedures. This has led to increased 
morbidity and mortality in the treatment 
of this disease. To effect early diagnosis, 
every patient with duodenal ulcer disease 
must be viewed as a potential Zollinger- 
Ellison syndrome. Each patient should 
have a properly done gastric analysis. Im- 
munoassay and endoscopy should also be 
done when available. In the absence of a 
palpable tumor at surgery, all suspicious 
cases should have a pancreatic tail biopsy. 
The following case report is a successful 
utilization of gastric analysis and pan- 
creatic tail biopsy enabling the surgeon to 
do the curative operation of total gastrec- 
tomy as the initial procedure: 


Reprint requests to Donald J. Palmisano, MD, 
13344 Chef Menteur Highway, New Orleans, 
Louisiana 70129. 


Case Report 

A 39-year-old Negro man was admitted to 
the Lallie Kemp Charity Hospital in October of 
1967 because of melena. He had experienced 
recurrent severe duodenal ulcer symptoms over 
the past years, with two previous episodes of 
upper gastrointestinal bleeding. Previous upper 
gastrointestinal barium studies showed chronic 
deformity of the duodenal bulb. Physical ex- 
amination on admission revealed an elevated 
blood pressure ranging from 193/130 to 180/105. 
Admission weight was 208 pounds, and height 
was 5 feet 11 inches. 

Laboratory studies on admission disclosed the 
following values: hematocrit 20 percent and 
white blood cell count 5,280/mm3, with a normal 
differential. The following studies were nor- 
mal: Fasting blood sugar, prothrombin time, 
blood urea nitrogen, serum sodium, serum potas- 
sium, serum calcium, serum phosphorus, serum 
amylase, serum glutamic oxaloacetic transami- 
nase, total serum protein, protein bound iodine, 
urinary 17-ketosteroids and urinary catecho- 
lamines, The stool guaiac test was positive. The 
urinalysis was normal. An electrocardiogram 
revealed left ventricular hypertrophy. The chest 
x-ray film showed an increased cardiothoracic 
ratio. The upper gastrointestinal series showed 
chronic deformity of the duodenal bulb; but 
neither an active ulcer crater nor an outlet ob- 
struction was noted. The rapid sequence intra- 
venous pyelogram was normal. 

The gastric analysis was done as follows: A 
12 hour collection of gastric juice was obtained 


May, 1974— Vol. 126, No. 5 


149 


ZOLLINGER-ELLISON SYNDROME— PALMISANO, ET AL 


via an indwelling Levin tube with proper place- 
ment verified by a radiograph of the abdomen. 
The 12 hour overnight collection yielded 1800 cc 
volume with 50 degrees (mEq/liter) free acid 
giving an output of 90 mEq free acid/ 12 hours. 
The total acid concentration was 97 degrees 
(mEq/liter) and 174 mEq/12 hours. Then a 
one hour specimen was collected with maximum 
histamine stimulation (0.04 m/kg body weight). 
The histamine was given subcutaneously at the 
start of the hour. One hundred cc were ob- 
tained with 64 degrees (mEq/liter) of free 
acid and 95 degrees (mEq/liter) total acid. 
From the criteria of total volume per 12 hours, 
free acid output per 12 hours, and the ratio 
test comparing basal to stimulated acid values, 
a diagnosis of the ZE syndrome was made. At 
operation, inspection of the duodenum showed 
a previously perforated ulcer sealed with omen- 
tum. The open stomach had another ulcer at 
the pylorus (Fig 1), and three additional gas- 
tric ulcers were noted. No tumor was palpable 


in the duodenum. The pancreas was carefully 
inspected, and no palpable tumor was noted. 
The tail of the pancreas (7x5x3 cm) and a 
pancreatic lymph node were removed. Histo- 
logical examination revealed diffuse islet cell 
hyperplasia and a microadenoma (Fig 2, 3). The 
lymph node showed a reticuloendothelial hyper- 
plasia. A total gastrectomy was done with con- 
struction of a Hunt-Lawrence jejunal pouch.^ 
After operation, the patient’s recovery was 
complicated by an abscess in the area of the 
esophagojejunostomy. The abscess was drained, 
and the patient was fed via a jejunostomy tube. 
He recovered satisfactorily and was discharged 
on a low carbohydrate, high protein diet sup- 
plemented with monthly injections of 50 ug vita- 
min B12. On March 21, 1968, his weight was 
142 pounds. He continued to do well without 
dietary difficulties or diarrhea and had no fur- 
ther ulcer symptoms. His hematocrit has re- 
mained normal, and his weight stabilized at 
182 pounds. The patient was readmitted to the 



Fig 1. Resected specimen showing one of the multiple gastric ulcers. This ulcer was at the 
pylorus. 


150 


J. Louisiana State M. Soc. 


ZOLLINGER-ELLISON SYNDROME— PALMISANO, ET AL 



Fig 2. Photomicrograph at 49X demonstrating the microadenoma. 


hospital in June, 1969 with a gun-shot wound 
of the chest and required tube thoracostomy be- 
cause of a pneumothorax. There was a lack of 
abdominal complaints or dietary problems. 

Discussion 

The duodenal ulcer disease process in 
this patient demanded intervention. How- 
ever, without the preoperative gastric 
analysis, a standard ulcer operation would 
have been done and this is inadequate for 
the Zollinger-Ellison syndrome. The ab- 
normal gastric analysis focused attention 
on the probability of the ZE syndrome, and 
definitive diagnosis was made with a pan- 
creatic tail biopsy. One half of the deaths 
in this syndrome have occurred shortly 
after inadequate surgical attempts to con- 
trol the gastric hypersecretion.^ Any pro- 
cedure less than total gastrectomy will 
usually prove to be futile. Since the ma- 
jority of patients have malignant tumors 
and since there is a high incidence of 
multiplicity in the benign tumors, defini- 


tive cure by removal of an obvious tumor 
is rare. Regression of the tumor was noted 
in some patients who had total gastrec- 
tomy for malignant ulcerogenic tumors.^ 

Since Zollinger and Ellison have called 
attention to this entity, many cases are 
now being reported. The proper treatment 
of an ulcer patient with the ZE syndrome 
demands a preoperative diagnosis. These 
are the available diagnostic aids: 

1. Upper gastrointestinal series. Pa- 
tients with symptomatic evidence of peptic 
ulcerations should have an upper gastro- 
intestinal series. Multiple ulcers and atyp- 
ical locations of ulcers should alert one to 
the possibility of the ZE syndrome. In- 
creased rugal folds, increased small bowel 
fluid and duodenal and jejunal hypermo- 
tility may also be present. 

2. Gastric analysis. While this is a 
simple diagnostic aid that can yield impor- 
tant information, it is often done improp- 
erly, and the results are confusing. The 


May, 1974— Vol. 126, No. 5 


151 


ZOLLINGER-ELLISON SYNDROME— PALMISANO, ET AL 









fVo*vH ^ 


> .V.H5 

Fig 3. Photomicrograph of microadenoma at 280X showing cellular detail. 


two most frequently used techniques are 
the (A) overnight 12 hour collection, and 
(B) the morning one hour basal and maxi- 
mum histamine stimulation samples. 

A. Overnight 12 hour collection. The 
placement of the Levin tube into the most 
dependent portion of the stomach is man- 
datory. Fluoroscopic placement can be 
done. Another technique is to have the 
physician place the tube himself on eve- 
ning rounds with proper external mea- 
surements taken into consideration, con- 
sidering the curve from the nose via the 
nasopharynx into the stomach. Then an 
abdominal x-ray is obtained to confirm 
proper placement. The patient is request- 
ed to lie on his left side during the collec- 
tion and expectorate any saliva rather 
than swallow it. The lab then measures 
volume and free acid and total acid. The 
acid concentration is reported in degrees 
(mEq/liter). The volume in liters times 
the degrees (mEq/liter) is equal to the 


acid output in mEq per 12 hour period, 
ie, 1.8 liters times 50 mEq/liter equals 90 
mEq/12 hours. Ellison utilized this tech- 
nique when he stated that greater than 1 
liter and 100 mEq output of free acid in 
12 hours is strongly suggestive of the ZE 
syndrome.® He further states that less 
than 3 percent of duodenal ulcer patients 
will have values of this magnitude.® Lab- 
oratories use titration with the Topfer in- 
dicator and 0.1 NaCH to obtain free acid 
values. 

B. Collection of a morning one hour 
basal and one hour maximum histamine 
stimulation sample. The patient is allowed 
nothing by mouth after midnight. At 7: 00 
a.m., a Levin tube is placed into the stom- 
ach, and all gastric juice is removed and 
discarded. Proper placement is essential 
(see under A). Then for one hour the 
gastric juice is collected and labeled as 
basal sample. At 7 : 30, the patient is given 
20 mg Chlorpheniramine intramuscularly 


152 


J. Louisiana State M. Soc. 


ZOLLINGER-ELLISON SYNDROME— PALMISANO, ET AL 


and at 8:00 he is given 0.04 mg per kg 
body weight of histamine acid phosphate 
subcutaneously. From 8:00 to 9:00, the 
histamine stimulated sample is collected. 
Aspiration of secretions should be done 
approximately every five minutes during 
the entire two hours. These specimens are 
then titrated with 0.1 normal NaOH to a 
pH of seven with a pH meter. The results 
should be reported as mEq per hour. The 
cc of NaOH used represents the number of 
degrees in mEq/liter. The mEq/liter 
times volume in liters of gastric juice col- 
lected in one hour is equal to mEq/hour. 
The basal value alone may suggest the ZE 
syndrome.'^ The ratio of the basal acid 
output (mEq/hour) to the histamine stim- 
ulated output (mEq/hour) is compared, 
and if the ratio is greater than .6 this sug- 
gests the ZE syndrome.® If a pH meter is 
not available, titrating the specimens 
using phenolphthalein as an indicator will 
give comparable values. 

3. Gastroduodenoscopy by use of the 
modern fiberoptic instruments provides 
excellent visualization, photography, and 
direct biopsy of lesions of the stomach and 
duodenum. The multiplicity of ulcers can 
best be determined this way. Also, in- 
creased rugal folds and hypermotility can 
be evaluated. 

4. Direct measurement of circulating 

gastrin levels at present can be done by 
two methods: Bio-assay and radio-im- 

munoassay. There are inherent problems 
in both, not the least being the availability 
of the tests. The bio-assay method at times 
is not sufficiently sensitive to detect 


gastrin. Also, high gastrin levels may 
cause actual inhibition of gastric secre- 
tions, under certain conditions in the 
intact biological system, leading to false 
conclusions. The radio-immunoassay meth- 
od appears to be more reliable; however, 
this is usually not readily available. 

Summary 

The Zollinger-Ellison syndrome of gas- 
tric hypersecretion and recurrent peptic 
ulceration secondary to gastrin secreting 
tumors usually of the pancreas is a well 
recognized entity. Unfortunately, many 
of the cases are found late after inade- 
quate attempts to control the gastric hy- 
persecretion. Early diagnosis is possible 
by considering every patient with peptic 
ulceration as a potential ZE syndrome. 
The available diagnostic tests are discussed 
and a patient with a microadenoma and 
islet cell hyperplasia is presented demon- 
strating early diagnosis utilizing gastric 
analysis and pancreatic tail biopsy. 

References 

1. Zollinger RM, Ellison EH: Primary peptic ulcera- 
tion of the jejunum associated with islet cell tumors of 
the pancreas. Ann Surg 142:709, 1955 

2. Friesen SR: Zollinger-Ellison syndrome. Current 
Problems in Surgery April, 1972 

3. Palmisano DJ, Brown JE: Total gastrectomy and 
the Hunt-Lawrence jejunal pouch. J La State Med Soc 
122:10, 1970 

4. Wilson SD, Ellison EH: Survival in patients with 
the Zollinger-Ellison syndrome treated by total gastrec- 
tomy. Amer J Surg 111:6, 1966 

5. Friesen SR: Effect of total gastrectomy on the 
Zollinger-Ellison tumor: observation by second-look pro- 
cedures. Surgery 62:609, 1967 

6. Ellison EH, Wilson SD : The Zollinger-Ellison syn- 
drome updated. Surg Clin N Amer 47:1115, 1967 

7. Segal HL: Gastric analysis. JAMA 196 :7, 1966 

8. Ruppert RD, Greenberger NJ, Berman NF, et al: 
Gastric secretion in ulcerogenic tumors of the pancreas. 
Ann Int Med 67 :808, 1967 


<S=1C=> 


May, 1974— Vol. 126, No. 5 


153 



BRENTWOOD HOSPITAL 

MIDSOUTH’S COMPREHENSIVE PSYCHIATRIC HOSPITAL CENTER 

Offers the Newest Concepts in Care for Neuro-Psychiatric Disorders: 
DRUG ABUSE, NEUROLOGICAL, ETC. 


A fully carpeted hospital: featuring private and semiprivate rooms in colorful 

decor; adjacent baths, color television and individual phones available; comfortable 
day rooms. 

DIAGNOSTIC FACILITIES: 

Medical Laboratory • Radiology • Electroencephalography • Electrocardiography 

Complete Psychological Testing 

THERAPEUTIC FACILITIES: 

Social Service • Occupational Therapy • Recreational Therapy 
Educational Therapy • Psychotherapy • Electroshock Therapy 

ACCREDITATIONS: 

Fully accredited by the Joint Commission on Accreditation of Hospitals 
Affiliated with Northwestern State University School of Nursing 
American Hospital Association • Louisiana Hospital Association 
Medicare • Blue Cross 
and other Medical Insurance Programs 

Brentwood also has an Anesthesia Department and an extensively equipped Phar- 
macy, as well as a modern Dietary Department, managed by a registered dietitian. 


BRENTWOOD HOSPITAL 

1800 IRVING PLACE 

Shreveport, Louisiana 7 MO I Phone (3 1 8) 424-658 1 


154 


J. Louisiana State M. Soc. 





Reye’s Syndrome 

• "This reporl- describes the occurrence of acute encephalopathy 
and hepatic dysfunction in three patients with autopsy findings in 
two siblings. There has been only one other report in the literature 
of Reye's syndrome affecting siblings." 

SURESH KUMARI, MD 
Lafayette 


CINCE the original description of the 
^ distinct clinicopathological entity in 
1963 by Reye, et aid there have been sev- 
eral repoii:s in the literature of the syn- 
drome. It has been shown that there is 
a definite association of the syndrome 
with varicella-zoster infection. 

This report describes the occurrence 
of acute encephalopathy and hepatic 
dysfunction in three patients with au- 
topsy findings in two siblings. There 
has been only one other report in the 
literature of Reye’s syndrome affecting 
sib lings. 2 

Case No. 1 : A 10-year-old Negro girl was 

well until three days prior to admission at 
which time the family noted the typical chicken- 
pox rash. She vomited the partially digested 
food on the morning of admission and started 
feeling weak from noon. She was given one 
baby aspirin every four hours during the four 
days prior to admission. 

On admission the patient’s temperature was 
103“ F. ; pulse rate was 130; and blood pres- 
sure was 130/80. 

Physical Examination 

She was noted to be a well developed, well 
nourished child who was lethargic but responsive 
to questions and oriented as to place, time and 
people. 

The skin showed the chickenpox lesions; some 
were already scabbed. Sclerae were not icteric. 
No papilledema was noted. The neck was supple. 
No signs of meningeal irritation were noted. 
Deep tendon reflexes were hypoactive, and there 
was no Babinski. During the physical examina- 
tion, the patient was noted to gradually lapse 
from lethargy into semicoma. 

Laboratory tests are shown in Table 3. 

The patient was given 50 percent glucose 
solution intravenously with no apparent improve- 
ment in sensorium. IV Mannitol and Decadron 
were tried for the possibility of cerebral edema. 
In spite of all efforts, the patient progressed 


into a coma and died approximately 17 hours 
after admission. 

X-rays of chest and skull were normal. 

Autopsy Findings 

Skin revealed small lesions in varying stages 
of healing distributed over face, trunk and ex- 
tremities sparing palms and soles. Lungs were 
congested. Prominent peribronchial nodes were 
present. A hemothorax (600 cc) was noted on 
the left side. Acute subendocardial hemorrhage 
was noted. Liver weighed 825 grams and was 
yellow, fatty and soft. Kidneys were pale and 
showed marked cloudy swelling of the tubules. 

The brain was swollen. No exudate was pres- 
ent in the meninges. No foci of hemorrhage or 
softening was present, and there were no areas 
of demyelination. 

Microscopically, the brain tissue was congested 
and edematous. Widespread acute hypoxic nerve 
cell changes were evident, especially in Som- 
mer’s sector of Ammon’s horns. No inflam- 
matory reaction had occurred. Myelin stains 
revealed pallor and irregular staining associated 
with edema but there was no evidence of demye- 
lination. 

Case No. 2: An 11-year-old Negro girl (sister 

of the patient in Case No. 1) presented to the 
Emergency Room with a five day history of 
chickenpox rash and one day history of fever 
.and vomiting. She was also noted to be lethargic 
on the day of admission. 

On admission, temperature was 100° F. ; pulse 
rate was 116; respiration rate was 20 /min. ; and 
blood pressure was 98/60. 

Physical Examination 

On physical examination, she was noted to be 
a thin female who was lethargic, but she re- 
sponded to questions. Skin revealed the crusted 
lesions on face, trunk and extremities. Sclerae 
were not icteric. Fundi showed sharp discs bi- 
laterally. Heart and lungs were normal. Ab- 
domen did not reveal any organomegaly. Deep 
tendon reflexes were 2-\- ; there was no Babinski. 

Arterial blood gases are sho^vn in Table 1, co- 
agulation profile in Table 2 and the rest of 
the laboratory studies are shown in Table 3. 


May, 1974— Vol. 126, No. 5 


155 


REYE’S SYNDROME— KUMARI 


given intravenous Mannitol with some response. 
Steroids were started for possible cerebral edema. 
Seven hours later, she again became agitated 
and delirious. Another dose of Mannitol had 
no effect in improving her sensorium. An ex- 
change transfusion with 2000 cc of blood was 
undertaken 24 hours after admission. During 
the procedure, she became opisthotonic and 
spiked temperatures to 105°. Breathing was 
noted to be of a Cheyne-Stokes pattern. Urinary 
output gradually decreased over a three hour 
period. She was given Mannitol at that time 
with marked improvement in respiration and in- 
crease in urinary output. However, her sen- 
sorium did not improve. 

Twenty-four hours after the first exchange, 
the second exchange transfusion was done with 
1400 cc of blood. During the second hospital 
day, she started having slight upper GI bleeding 
which was treated with a saline irrigation and 
Maalox. 

After the second exchange, there were some 
mechanical problems with CVP, and the patient 


TABLE 3 

LABORATORY STUDIES 



PT. 1 - J.A. 

PT. 11 - L.A. 

PT. Ill - W.T. 

SCOT 

1160 

990 

600 

Bilirubin 

Total 

Not done 

2.4 mgm% 

3 . 7 mgm% 

Direct 

Not done 

1.25 mgm% 

3.0 mgm% 

Aik. Phos. 

108 I.U. 

144 I.U. 

11.1 I.U. 

Blood Sugar 

40 mgm% 

113 mgm% 

67 mgm% 

BUN 

17.5 mgm% 

27 mgm% 

79 mgm% 

Creatinine 

Not done 

1 mgm% 

5.8 mgra% 

CBC 

Hb 

14.3 

12.1 

10 

Hct 

40.5 

36.9 

28 

WBC 

24,900 

10,100 

91,200 

Platelets 

Normal 

275,000 

111,000 

Salicylates 

18 mgm% 

Not done 

8 mgm% 

U/A 

Spec. Grav. 1.027 
Hb. — small 
Glucose 14- 
Protein — trace 

Spec. Grav. 1.031 
Ketones — small 
Glucose- -negative 
Protein- -negative 

Spec. Grav. 1.011 
Ketones--small 
RBC’s > 100 

CSF 

Glucose 

33.4 mgm% 

Not done 

61 mgm% 

Protein 

18.5 mgm% 

Not done 

99 mgm% 

Cells 

0 

Not done 

100 RBC'S 

Blood Anunonia 

Not done 

190 micrograms 

347 micrograms 

Cultures 

Blood 

Negative 

Negative 

Negative 

CSF 

Negative 

Not done 

Negative 

Urine 

Negative 

Negative 

Negative 

Throat 

Negative 

Negative 

Negative 


Approximately three hours after admission, 
she was noted to be less responsive; and she 
became very agitated and delirious. She was 

TABLE 1 



TABLE 2 

COAGULATION STUDIES 
PT. II -LA. 


FACTOR 

NORMAL 

PATIENT 

Fibrinogen 

170-410 mg% 

185 mg% 

Pro. Time 

11.9 sec. 

20.4 sec. 

PTT 

32.4 sec. 

40.5 sec. 

Platelets 

200-400,000 

275,000 


156 


J. Louisiana State M. Soc. 


REYE’S SYNDROME— KUMARI 


was given more fluid inadvertently. She de- 
veloped tachycardia, tachypnea and rales 
throughout the lungs. She was thought to be 
in pulmonary edema and was digitalized. Four 
hours later, the patient had a generalized tonic 
clonic seizure which was controlled with IM 
phenobarbital. Despite all efforts, she died 58 
hours after admission. 

On further questioning the family about the 
possible ingestion of toxins, they mentioned that 
they made tea out of some herbs from the yard, 
and all the family members drank it a few days 
before these children were admitted. Urine and 
blood from the second patient and the home- 
made tea were analyzed. No toxins were found. 

Autopsy Findings 

Skin showed multiple lesions varying from 
vesicles to crusted lesions. Lungs showed pul- 
monary edema, hemorrhagic bronchitis and focal 
bronchopneumonia. Heart showed acute subendo- 
cardial hemorrhage. Liver weighed 1000 grams 
grossly; it was yellow, fatty and soft. There 
was a marked fatty change microscopically. 

Kidneys showed marked hyperemia of papil- 
lae and cloudy swelling of convoluted tubules. 

The brain was generally swollen. Meninges 
were congested, but there was no exudate. 

Microscopically, the brain tissue was ede- 
matous and congested. Widespread severe hy- 
poxic changes were evident at all levels, most 
marked in the cerebral cortex. No inflammatory 
reaction was noted. Myelin stains showed pal- 
lor associated with edema in white matter im- 
mediately adjacent to gray matter structures. 
Even in the most advanced parts of the diffuse 
nerve change, there was no inflammatory re- 
action. 

The changes in the brain, similar to but more 
advanced and extensive than those in her sibling, 
were acute, not associated with inflammatory 
reaction and characteristic of hypoxia with or 
without associated hypoglycemia. 

Case No. 3: A 2-year-old Negro boy was ad- 

mitted in a semicomatose state with a four day 
history of flu-like symptoms and a one day his- 
tory of semicomatose state. A few hours be- 
fore admission here, he was seen by a physician 
for seizures and was given phenobarbital. Dur- 
ing his illness, he was given 1/4 of a Bayer’s 
aspirin tablet every 6 to 8 hours for one day for 
fever, and cough syrup for two days prior to 
admission. 

There was no history of trauma or ingestion 
of toxins. 

On admission, the temperature was 100.6° P. ; 
pulse rate was 160/min. ; and respiration rate 
was 40 /min. 


Physical Examination 

He was noted to be a well developed, well 
nourished child in a semicomatose state. Sclerae 
were nonicteric. The pupils were small and re- 
acted to light; fundi were normal. The neck 
was questionably stiff. Heart and lungs were 
within normal limits. No masses were felt in 
the abdomen. The patient responded to pain. 
Extremities were extended and spastic. Deep 
tendon reflexes were positive; no Babinski was 
present. 

Blood gases are shown in Table 1 ; laboratory 
data are shown in Table 3. 

Exchange transfusion was undertaken 24 hours 
after admission. There was slight improvement 
in the urinary output after the exchange, but 
no change was noted in the neurological status. 
Another exchange transfusion was done 24 hours 
later, still with no remarkable improvement in 
the sensorium. Patient was maintained on sup- 
portive therapy. Approximately a week after 
admission, he started to show improvement by 
moving the extremities to deep pain. He gradu- 
ally came around within the next two weeks, 
and was discharged one month after admission 
with NG tube for feeding purposes as he was 
not able to chew or swallow. He was seen in 
the clinic once two weeks after discharge. He 
was eating and drinking well without the NG 
tube. Two weeks later, he expired at home; and 
no autopsy was done. 

Discussion 

In the epidemiological study of Reye’s 
syndrome by Glick, et al,^ they noted 
an increased incidence between January 
through June. All three of our patients 
came in the first week of March. This 
increase in late winter and early spring 
is likely to be related to the outbreak 
of influenza B infection and varicella- 
zoster. At least three-fourths of these 
patients were described as having some 
degree of metabolic acidosis.^ It may 
be related in part to salicylate inges- 
tion. The clinical presentation of the 
patients and the progression of the dis- 
ease seem to be the same in all the pa- 
tients described. The common clinical 
findings in these patients are shown in 
Table 4. The neurological symptoms ap- 
pear three to four days after the onset 
of viral illness. Vomiting appears to 
herald the onset of CNS symptoms. The 
progression of the cerebral dysfunction 


May, 1974— Vol. 126, No. 5 


157 


REYE’S SYNDROME— KUMARI 


can take place in a few hours and some- 
times in less than an hour as it hap- 
pened to the patient in Case No. 1. In 
an attempt to correlate the laboratory 
values with the outcome, Huttenlocher® 
finds blood ammonia values to be help- 
ful. However, among our patients the 
one who survived initially had higher 
than 300 micrograms of ammonia. The 
patient reported as Case No. 2, who 
died, had a lower level (190 micro- 
grams). 

TABLE 4 

CLINICAL FINDINGS IN THREE PATIENTS 


No. of 

Findings Patients 

Vomiting 3 

Lethargy and coma 3 

Rigidity 3 

Fever 3 

Bleeding manifestations 1 

Convulsions 2 

Delirium 2 

Varicella 2 

Jaundice 0 


This syndrome has been known to be 
definitely associated with chickenpox. 
The patient reported as Case No. 1, pre- 
sented on admission with hypoglycemia 
and also had a salicylate level of 18 
mgm whereas the other two patients 
had no hypoglycemia. It is possible that 
hypoglycemia is caused by interference 
with the carbohydrate metabolism by 
salicylates rather than the fatty infil- 
tration of the liver. All three patients 
had polymorphonuclear leukocytosis 
without any evidence of infection. Co- 
agulation studies performed in one of 
our patients showed prolonged PT, PTT 
indicating the hepatic dysfunction as de- 
scribed by Schartz.® Disseminated in- 
travascular coagulation should always 
be considered in any patient who is seri- 
ously ill and starts bleeding. Other clin- 
ical and laboratory tests should be help- 
ful in making the differentiation. It is 
very important to make this differentia- 
tion between the bleeding due to dis- 
seminated intravascular coagulation and 


that due to hepatic failure as the treat- 
ment is different. In case of bleeding 
in Reye’s syndrome, heparin is contra- 
indicated ; and vitamin K, even in mas- 
sive doses, is of little value. The treat- 
ment of choice is replacement of liver 
factors by infusing fresh plasma. 

Availability of liver function studies 
and blood ammonia will make it easier 
to substantiate the clinically suspected 
Reye’s syndrome. Medullary failure is 
more likely to occur in this syndrome 
after a lumbar puncture. Unless there 
are obvious physical signs of meningitis, 
Byers^ does not recommend an LP on 
patients suspected of having Reye’s syn- 
drome. LP in our patients did not re- 
veal any evidence of infection. The pa- 
tient in Case No. 1, who had hypogly- 
cemia, also had low sugar in the CSF. 

All three patients showed evidence 
of impaired renal function by elevated 
BUN, creatinine and casts. 

There have been several therapeutic 
approaches described in the literature. 
Therapy should be aimed at: 

1. Treatment of hypoglycemia. 

2. Treatment of cerebral edema. 

3. Measures to decrease the produc- 
tion of ammonia. 

4. Supportive treatment for respira- 
tory failure if it occurs, and anti- 
biotics if infection supervenes. 

5. Early diagnosis and treatment of 
coagulation problems. 

6. Maintaining the good renal func- 
tion. 

7. Measures to remove the excessive 
blood ammonia. 

Hypoglycemia is a frequent manifes- 
tation especially in patients who have 
had salicylates administered for fever. 
Blood sugar should be frequently moni- 
tored with Dextrostix even when the 
patient is on IV fluids. To control the 
cerebral edema. Mannitol, IG/Kg, in- 
travenously should be used. Dexa- 
methasone can be used if there is no 
GI bleeding. Since encephalopathy may 


158 


J. Louisiana State M. Soc. 


REYE’S SYNDROME— KUMARI 


be related to blood ammonia,® measures 
should be taken to decrease its produc- 
tion. If the patient has GI bleeding 
secondary to liver failure, measures to 
stop the bleeding should be taken as 
the blood in the GI tract will elevate 
blood ammonia. Neomycin orally and 
by enema helps to decrease the ammonia 
production by altering the intestinal 
flora. If sedation is needed for agita- 
tion and restlessness, drugs excreted 
through the kidney (phenobarbital) 
must be chosen. Morphine and paralde- 
hyde are contraindicated. 

If respiratory failure occurs, respira- 
tion should be supported by mechanical 
ventilation. 

In case of a bleeding problem, one 
should differentiate the bleeding sec- 
ondary to liver failure from dissemi- 
nated intravascular coagulation as the 
treatment is different. The treatment 
of choice for bleeding in liver failure is 
replacement of liver factors (Prothrom- 
bin, Factor VII, IX, X, Fibrinogen and 
Factor V) by plasma transfusion. Vita- 
min K is ineffective in controlling bleed- 
ing under these circumstances. 

Treatment should be aimed at main- 
taining the normal electrolyte balance 
and intravascular volume to assure good 
urinary output. An attempt should be 
made to remove the excessive blood 
ammonia either by peritoneal dialysis 
or exchange transfusion. There is one 
patient in the literature of Reye’s syn- 
drome who was successfully treated by 
peritoneal dialysis.® 

Exchange transfusion should be per- 
formed with fresh whole blood prior 
to the onset of medullary dysfunction, 
and it should be repeated every 12 hours. 
Ammonia content of stored blood rises 


precipitously with storage,®^ so the blood 
for exchange transfusion should be as 
fresh as possible. 

The therapy of Reye’s syndrome 
should be very vigorous and multi- 
faceted. With a high index of suspicion, 
early diagnosis and vigorous treatment, 
we should be able to improve the mor- 
tality rate considerably. 

Summary 

Three patients with Reye’s syndrome 
are described. An attempt is made to 
describe the clinicopathological findings 
and therapeutic approach to this syn- 
drome. 

Acknowledgments 

I thank Dr. Ann L. Thorn of our 
Pathology Department for doing the au- 
topsy on these patients, and Dr. Paul 
McGarry of the Pathology Department 
at LSU in New Orleans for his help in 
evaluating the neuropathology in these 
patients. 

References 

1. Reye RDK, Morgan G. Baral J: Encephalopathy 
and fatty degeneration of the viscera, a disease entity 
in childhood. Lancet 2:749, 1963 

2. Click TH, et al: Acute encephalopathy and hepatic 
dysfunction, associated with chickenpox in siblings. Am 
J Dis Child 119 :68, 1970 

3. Click TH, Lickosky WH, Levitt LP, et al : Reye’s 
syndrome: An epidemiologic approach. Pediatrics 46:371, 
1970 

4. Simpson H : Encephalopathy and fatty degeneration 
of the viscera, acid base observations. Lancet p. 1274, 
Dec, 1966 

5. Huttenlocher PR: Reye’s syndrome: Relation of 

outcome to therapy. J Pediatr 80:846, 1972 

6. Schwartz AD : The coagulation defect in Reye’s 
syndrome. J Pediatr 78 :326, 1971 

7. Byers RK : To tap or not to tap. Pediatrics 51:561, 
1973 

8. Huttenlocher PR, Schwartz AD, Klatskin G: Reye’s 
syndrome: Ammonia intoxication as a possible factor in 
the encephalopathy. Pediatrics 43 :443, 1969 

9. Pross DC, et al: Reye’s syndrome treated by peri- 
toneal dialysis. Pediatrics 45 :845, 1970 

10. Spear PW, Martin C, Cincotti JJ : Ammonia levels 
in transfused blood. J Lab Clin Med 48:702, 1966 


May, 1974 — Vol. 126, No. 5 


159 


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Removal of 'Tost’" Intravascular Catheters 


• "We are reporting two patients in whom the nonopaque, silastic 
segment of ventriculo-atrial shunts had been lost. The angiocar- 
diogram from one showed a large thrombus surrounding the catheter 
debris necessitating removal at thoracotomy. On the other patient 
there was no thrombus surrounding the catheter debris on the 
angiocardiogram, so we removed it transluminally. These cases illus- 
trate the occasional need for angiography prior to removal of 
foreign material from the heart." 

FRANCIS A. PUYAU, MD 
STEPHEN GAMMILL, MD 
New Orleans 


A PPROXIM ATELY 32 patients with 
“lost” intravascular catheter debris 
have been presented in medical publica- 
tions to date.^'^ Angiocardiography has 
not been stressed in the preliminary 
evaluation of these patients prior to re- 
moval of the catheter debris. Three pa- 
tients have been referred to us in which 
angiography was helpful in their evalua- 
tion prior to consideration of removal of 
the catheter debris. We have reported 
one in a separate communication.^ We 
shall mention it briefly and discuss the 
other two in depth. 

Case Presentations 

Case No. 1 : TB had a ventriculo-atrial shunt 

performed at age 2. The shunt was not func- 
tioning at age 7 and was removed. The neuro- 
surgeon who removed the valve noted that the 
distal silastic catheter was broken off. The 
child experienced no immediate difficulty, but 
eventually he began to suffer with intermittent 
episodes of fever. 

At 8 years of age, he was hospitalized for an 
episode of “right upper lobe pneumonia.” He 
responded slowly to treatment and continued to 
have a low grade temperature. Pulmonary em- 
bolus was suspected when a MAA lung scan 


Dr. Puyau is Head, Department of Radiology, 
LSU School of Medicine, New Orleans, Director 
of Pediatric Cardiac Catherization Laboratory, 
and Assistant Radiologist, Charity Hospital, New 
Orleans. 

Dr. Gammill is Associate Professor of Radiol- 
ogy, Tulane University School of Medicine, and 
Assistant Radiologist, Charity Hospital New Or- 
leans. 


showed absence of perfusion of the right upper 
lobe. 

The child was referred for angiography to 
locate the position of the lost silastic tubing in 
the circulation. An injection of contrast into 
the superior vena cava showed a narrow radio- 
lucent filling defect (Fig 1). In the right atrium, 
a large radiolucent filling defect was noted 
(Fig 2a,b). We interpreted the latter as a large 
thrombus, and the patient was referred to a 
cardiac surgeon for operative removal. At open 
heart surgery, the silastic tubing and a 3 cm, 
well organized, pedunculated thrombus were re- 
moved from the right atrium. The patient has 
done well postoperatively. 



Fig 1. (Case 1); Anterior-posterior view of 
angiocardiogram obtained with injection of con- 
trast into the superior vena cava. The arrow 
points at a lucent defect caused by a silastic 
catheter. 

Case No. 2: DF had a ventriculo-atrial shunt 

performed at 10 years of age. At age 11, the 
pump failed. When the neurosurgeon removed 


May, 1974— Vol. 126, No. 5 


161 



LOST CATHETERS— PUYAU, ET AL 



Fig 2a. (Case 1); Anterior-posterior view of 
the angiocardiogram one second after injection. 
Contrast fills right atrium and ventricle. The 
arrow is directed at a large lucent defect caused 
by a thrombus in the right atrium. 



Fig 2b. ( Case 1 ) : Lateral view of the an- 

giocardiogram obtained with injection of con- 
trast into the superior vena cava. The arrow 
points at a lucent defect caused by a large throm- 
bus in the right atrium. 

the valve, he noticed that the silastic catheter 
was no longer attached. The radiopaque tip, 
formerly noted to be in the right atrium had 
migrated into the right ventricle (Fig 3). 

The patient was referred to us for translumi- 
nal removal of the catheter debris. Prior to 
attempted removal, we performed an angio- 
cardiogram by injecting contrast material into 
the superior vena cava. The angiocardiogram 
showed a lucent defect in the superior vena 
cava thought to be the catheter (Fig 3). There 
was no thrombus attached to the catheter debris. 
We attempted to snare the nonopaque segment 



Fig 3. (Case 2): Anterior-posterior view of 
the angiocardiogram obtained with injection of 
contrast into the superior vena cava. Contrast 
fills the cava, right atrium, right ventricle and 
pulmonary arteries. The black arrow is di- 
rected at the radiopaque tip of the silastic 
catheter in the right ventricle. The open arrow 
is directed at the lucent defect in the superior 
vena cava produced by the silastic catheter. 

of the silastic catheter in the superior vena cava 
by inserting a thin walled, 8 French, blunt end 
catheter through the right femoral vein per- 
cutaneously. We were able to do so with the 
aid of a 9 French sheath catheter inserter. We 
doubled a .025 inch guide wire and forced it 
through the catheter before inserting both 
through the sheath catheter inserter. Being un- 
able to snare the nonopaque silastic catheter, 
we then advanced our catheter and loop into 
the right ventricle and attempted to snare the 
opaque tip of the silastic catheter. The tip was 
dislodged, and it moved to the inferior margin 
of the pulmonary valve. The patient experi- 
enced several short episodes of ventricular tachy- 
cardia when the catheter migrated and while 
the loop was being manipulated in the right ven- 
tricle. We were able to snare the opaque tip 
(Fig 4) and then remove it. 

Discussion 

We have found no reports discussing 
the need for venography or angiocardi- 
ography in the evaluation of patients 
with intravascular catheter debris. Case 
1 demonstrates that this step is indis- 
pensable in the proper evaluation of 
these patients, as a large thrombus may 
form around the catheter debris especial- 
ly if it has been free in the circulation 
for several months or a year as was the 


162 


J. Louisiana State M. Soc. 



LOST CATHETERS— PUYAU, ET AL 



Fig 4. (Case 2) ; Anterior-posterior view of 
chest roentgenogram. The arrow is directed at 
the catheter and wire loop tip tightened around 
the radiopaque tip of the silastic catheter just 
before removal. 

situation in Case 1. Bloomfield^ empha- 
sized in a previous publication that 
catheter debris should be removed as 
soon as it is discovered to prevent throm- 
bus forming around it, as well as other 
complications developing from it. Our 
Case 1 certainly substantiates this phi- 
losophy. 

Certainly transluminal removal is the 
procedure of choice in the removal of 
catheter debris if no thrombus is pres- 
ent, as was the situation in Case 2. 
Thoracotomy is the procedure of choice, 
however, if a large thrombus is attached 
to the debris. The thrombus must be 
removed in toto lest it be life threaten- 
ing because of the danger of it pro- 
ducing a pulmonary embolus if dis- 
lodged. 

We have dealt with a burned patient^ 
in whom an intercath had been broken 
off in the left innominate vein. We 
planned to perform an innominate veno- 
gram prior to attempting to remove it 
transluminally to evaluate its position. 
The patient died of complications be- 
cause of her burns, however, before we 
could attempt any procedure. At necrop- 
sy, the broken intercath had pierced the 
lumen of the vein and was extraluminal 


except for a tiny tip too small to be 
snared. A venogram would have saved 
an ill advised attempt at removal since 
the radiopaque tubing could have been 
shown to have been outside the vein. Al- 
though we were unable to snare the non- 
opaque segment of the catheter debris 
in Case 2, the angiogram helped us lo- 
cate it so that we were able to at least 
attempt to snare it. 

We have found no repoiTs describing 
the removal of nonopaque ventriculo- 
atrial shunt catheter debris. The distal 
segment of this type of shunt is non- 
opaque except for the tip. One case re- 
port^ described the removal of the distal 
segment of a Halter valve ; but the entire 
distal segment was radiopaque. 

We attempted to snare the nonopaque 
part of the debris in our Case 2, as we 
prefeiTed not to insert our catheter and 
snare into the right ventricle if possible. 
Another patient that we reported pre- 
viously" went into ventricular tachycar- 
dia when we inserted the catheter and 
snare into the right ventricle while at- 
tempting to get them into the pulmonary 
artery. The patient required shocking to 
restore his cardiac rhythm to normal. 
The intercath was finally removed trans- 
luminally at another hospital. 

We were able to insert a blunt end, 
thin walled 8 French catheter into the 
femoral vein with the aid of the 9 French 
mylar sheath. This was helpful in sev- 
eral ways. It eliminated the necessity 
for a tapered catheter tip and made con- 
trol of the loop snare much easier and 
more efficient. Also, we were able to run 
the doubled guide wire through the 8 
French catheter before inserting it into 
the patient by pushing the two ends of 
the wire through the catheter. The 
sheath also enabled us to manipulate the 
catheter easier than is the usual case 
with a percutaneous catheter. 

Conclusions 

Angiography was an important step in 
the evaluation of two patients with ra- 


May, 1974— Vol. 126, No. 5 


163 



LOST CATHETERS— PUYAU, ET AL 


diolucent catheters lost in the circula- 
tion. The studies identified a large 
thrombus in one, and the proximal end 
of the catheter in the other. 

It was possible to remove a nonopaque 
silastic catheter by snaring an opaque 
tip. A mylar sheath catheter inserter 
was of benefit in inserting and manipu- 
lating the catheter and wire loop used to 
retrieve the catheter. 


References 

1. Bloomfield DA: Techniques of nonsurgical retrieval 
of iatrogenic foreign bodies from the heart. Amer J 
Cardiol, 27 :538-45. 1971 

2. Dalter CT, Rosch J, Bilbao M : Transluminal extrac- 
tion of catheter and guide fragments from the heart and 
great vessels. 29 collected cases. Amer J Roentgen, 
111:467-73, 1971 

3. Gammill SL, Smith SL : Removal of “lost” catheters 
and guide wires without operation. Sou Med J, 65:463-65, 
1972 

4. Tatoumi T, Howland WJ : Retrieval of ventriculo- 
atrial shunt catheter from heart by venous catheteriza- 
tion technique. J Neurosurg, 32:593-96, 1970 


HieeRnia 

f iT J nanonaL 

eariK 


164 


J. Louisiana State M. Soc. 




Medical Grand Roun 

from 

Touro Infirmary 


Multiple Myeloma 


Edited by SYDNEY JACOBS, MD 
New Orleans 


Dr. Erol Turer:<^^ A 70-year-old Ne- 
gro woman was admitted with a history 
of weight loss, backache and chest pain 
of six to seven years’ duration; these 
had become worse two months before ad- 
mission. She did not recall any sort of 
infection, bleeding disorder or signifi- 
cant illness in the recent or the remote 
past, knew of no diseases “running in 
her family,” and said that she had sel- 
dom used either alcohol or tobacco. 

The patient was small (64", 100 lbs) 
emaciated and was slightly confused, ex- 
hibiting slow, slurred speech. Both up- 
per eyelids were ptotic. Her blood pres- 
sure was 130/180 ; her pulse rate was 
100 ; and she was afebrile. Grossly 


limited expansion of the chest was at- 
tributed to right-sided chest pain since 
there were no rales or rubs. The car- 
diac apex beat was located in the left 
fifth intercostal space 1 cm beyond the 
mid-clavicular line ; there was sinus 
rhythm with only an occasional ven- 
tricular premature beat. Dorsal ky- 
phosis was marked as was tenderness 
over the 11th and 12th thoracic ver- 
tebral spines. The liver was palpated 
2 cm below the right costal margin ; but 
apparently she had neither splenomeg- 
aly nor an abdominal mass. Muscular 
wasting of all four extremities was easily 
discerned ; but the patient appeared to 
retain proper control of motor func- 
tions. I found no disturbance on test- 


Intern, Touro Infirmary. 

May, 1974— Vol. 126, No. 5 


165 


MEDICAL GRAND ROUNDS— Touro Infirmary 


ing cranial nerve function or of deep 
tendon reflexes. 

Dr. Sydney Jacobs What was your 
admission diagnosis? 

Dr. Turer: Multiple myeloma. This 
was supported by our initial laboratory 
studies which demonstrated : 9,900 leu- 
kocytes (56 segmenters, 29 lympho- 
cytes, 11 monocytes, 2 plasma cells) ; 
hemoglobin 7.9, and hematocrit 24; es- 
tablishing indices of MCV 92 and MCV 
29.7. Chest x-ray disclosed bilateral 
multiple rib fractures of varying ages, 
while compression fractures of the 11th 
and 12th thoracic vertebrae were ap- 
propriately visualized. On more de- 
tailed study, we learned that the sedi- 
mentation rate was 136. The serum pro- 
teins measured 11.3 (albumin 4.5, globu- 
lin 6.8). The blood urea nitrogen (BUN) 

Chairman, Department of Medicine, Touro 
Infirmary; Clinical professor of medicine, Tulane 
University School of Medicine. 


was 66 although the creatinine was 
2.5, and the creatinine clearance was 
27 cc/minute; and there was 3+ al- 
buminuria. The serum calcium was 14.6. 
The phosphorus was 3.6. The fasting 
blood sugar was 85. There were normal 
values for the serum glutamic oxaloacetic 
transaminase (SCOT), the serum gluta- 
mic pyruvic transaminase (SGPT) for 
the bilirubin content and for thyroxin 
estimates. 

As soon as we learned that the pa- 
tient had a urinary infection, we started 
Gentamycin and the BUN increased to 
105; so we discontinued the Gentamycin 
and administered steroids only to note 
that the fasting blood sugar rose to 
400 mg percent. 

Dr. Carlos Alfaro You may be in- 
terested to learn how we arrived at the 
diagnosis of multiple myeloma in this 

(c)First year medicine resident, Touro Infir- 
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166 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS— Touro Infirmary 


patient. She presented to the Admit 
Clinic one morning complaining of severe 
weakness, loss of appetite and loss of 
weight, mainly during the preceding 
two months. 

When she had the CBC done. Dr. 
Bradbum called from Pathology urging 
me to admit her for detailed studies 
because the original blood smears were 
suggestive of multiple myeloma. After 
the x-rays and the blood studies, the 
diagnosis was about 90 percent clear. 

She has complained ever since she 
came of severe pain in the right side 
of the chest and also in the lower back, 
especially at the level of T-11 and L-1, 
which were the collapsed vertebrae. 

According to the literature, the most 
frequent pattern of infections in pa- 
tients with myeloma has been pneumo- 
coccal pneumonia; but the pattern of 
infection has changed and urinary in- 
fection with gram-negative bacteria is 
currently believed to be a more frequent 
cause of sepsis. 

The uric acid in this patient has been 
normal; and it is well known that pa- 
tients with myeloma may have different 
factors contributing to kidney disease 
which include hyperuricemia, hypergly- 
cemia and very rare cases with nephro- 
calcinosis, with infiltration of amyloid 
in the kidneys and infiltration with mye- 
loma in this organ. 

Dr. Charles Conley: Adherence of 

red cells to each other — rouleaux for- 
mation — is a feature of multiple mye- 
loma. “Undifferentiated” plasma cells 
are malignant and are distinguished 
from the “differentiated” or “benign” 
plasma cells. Our finding of a high per- 
centage of immature or “poorly differ- 
entiated” myeloma cells in the bone mar- 
row indicates a florid state of the neo- 
plasm. The rectal biopsy was negative 
for amyloid. 

Mrs. Lucille Payne: The patient 

had pain severe enough to require fre- 

Pathologist, Touro Infirmary. 

Staff nurse, Touro Infirmary. 


quent use of Dilaudid ; but this pain re- 
lief made it possible to change her posi- 
tion frequently to keep her free of bed- 
sores. 

Dr. Jacobs: It is far better to work 
to prevent a bedsore than to contend 
with it once it has developed. 

Mrs. Patricia Roig:<^^ Miss Hotard 
talked with the family about nursing 
home placement; they refused because 
they said that they would take shifts 
watching her and they would even hire 
a sitter if need be. They are very sup- 
portive. 

Dr. Jacobs: This is most comforting 
today to hear about families who still be- 
lieve that tender loving care belongs at 
home. 

Dr. German Beltran: Pain is one of 
the most common manifestations in mul- 
tiple myeloma, although it isn’t of much 
help in establishing the diagnosis be- 
cause it is nonspecific. Because of the 
pain, the patient went to bed about two 
months before she was admitted, and 
through immobilization the serum cal- 
cium probably started to increase. With 
multiple myeloma, hypercalcemia al- 
ways becomes more severe whenever the 
patient is immobilized. Hypercalcemia 
leads to hypercalciuria and proteinuria 
and very rapidly to dehydration and to 
deterioration of hepatic function. The 
patient progressively becomes less lucid 
than before and fails to drink water, 
thereby setting up a kind of vicious 
cycle. Therapy against myeloma often 
decreases the pain, and then it is pos- 
sible to make these patients start walk- 
ing ; and that improves the situation 
tremendously. A bedridden patient is 
prone to develop the pattern of progres- 
sive hypercalcemic deterioration of the 
renal function and dehydration. The 
BUN and the calcium decreased rather 
rapidly, not because of corticosteroid 

O) Clinical counselor — Social Service, Mental 
Health Center, Touro Infirmary. 

(s)Associate professor of medicine, Tulane 
University School of Medicine. 


May, 1974— Vol. 126, No. 5 


167 


MEDICAL GRAND ROUNDS— Touro Infirmary 


therapy but rather as a result of cor- 
rection of dehydration. Rehydration at 
times is the only thing that needs to be 
done. 

How does one establish a diagnosis 
of multiple myeloma? There are essen- 
tially three important elements: One is 
demonstration of plasmacytosis among 
bone marrow cells. (Remember that you 
may at times aspirate only normal mar- 
row constituents. With strong suspicion 
of myeloma, you may need to aspirate 
at another site). 

The finding of abnormal proteins pro- 
vides the second important parameter to 
establish the diagnosis. Seventy-five or 
80 percent of patients with myeloma 
have abnormal increase of a homoge- 
neous globulin, usually IgG, less com- 
monly IgA and occasionally either IgD 
or IgE. An abnormal protein, the Bence- 
Jones protein, is found in the urine of 
40 to 50 percent of patients with mul- 


tiple myeloma. This protein, the light 
chain of the immune globulin, is pre- 
cipitated when the urine is acidified ; 
and it is suspended when the urine is 
boiled, with re-precipitation when the 
urine staii:s cooling. Patients with mul- 
tiple myeloma and proteinuria to the 
degree that this patient exhibited usual- 
ly have the protein of Bence-Jones. 

Unfortunately, acidification of the 
urine fails to detect the presence of this 
protein in 25 to 30 percent of patients 
with multiple myeloma, and there is 
need for more sensitive methodology 
such as the electrophoresis of the con- 
centrated urinary protein or immuno- 
electrophoresis. 

Patients with multiple myeloma fre- 
quently have urinary tract infections 
and alkaline urine to which much acidi- 
fying buffer must be added if the uri- 
nary pH is to be lowered adequately 
for the detection of this protein. Failure 


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MEDICAL GRAND ROUNDS— Touro Infirmary 


to remember this precaution is one of 
the most common reasons why the pro- 
tein is not detected. Again remember 
that the use of Labstix fails to detect 
the protein of Bence-Jones. Some mye- 
loma patients have Bence-Jones pro- 
teinuria but do not have an abnormal 
protein in the plasma. Such patients 
develop a myeloma kidney wherein the 
abnormal protein is filtered by the renal 
glomerulus and is not reabsorbed by the 
renal tubule. In this process, the renal 
tubular cells are injured and undergo 
a marked degree of necrosis with actual 
precipitation of the abnormal protein 
and closing of the proximal and distal 
tubules of the kidneys. This is one of 
the reasons why patients with multiple 
myeloma might develop renal insuffi- 
ciency. A second reason, a correctable 
and preventable cause for uremia, is the 
development of hypercalcemia with de- 
hydration. Another reason is urinary 
tract infection which usually responds 
to adequate therapy. Myeloma kidney, 
amyloidosis and nephrocalcinosis are 
still not amenable to our current ther- 
apies. And this is important because 
uremia kills patients with myeloma, and 
it is probably one of the leading causes 
of death in these patients, along with 
infections and hemorrhage. 

Dr. Conley: When a Bence-Jones pro- 
tein test is ordered, we do a heat test. 
Routinely we use both the Labstix and 
the sulfo-salicylic acid precipitation tech- 
niques. 

Dr. Beltran: The detection of bony 

lesions provides the third and the fourth 
in the criteria to diagnose multiple mye- 
loma. About 90 percent of patients with 
multiple myeloma have some detectable 
abnormality of the bones, sometimes 
generalized demineralization with per- 
haps the occurrence of pathological frac- 
tures; most commonly, the bone sites 
are the spine and the ribs. This patient 
shows evidence of compression fracture 
of one of her lumbar vertebrae and 
pathological fractures of several ribs. 


Since multiple myeloma is a disease 
of elderly people, it is sometimes dif- 
ficult to know whether bone deminerali- 
zation is simply due to senile osteopo- 
rosis or to myeloma. There is, of course, 
a very small number of patients with 
myeloma on whom no bony abnormali- 
ties can be detected radiologically, and 
yet they complain of pain. We have to 
remember that the patient has to lose 
from 30 to 49 percent of all the calcium 
in the bone before anything shows in 
the x-ray. 

Various hematological complications 
(thrombocytopenia, coagulation abnor- 
malities) result when abnormal globulins 
form complexes with the protein. 

Chemotherapy is but one part of the 
management. Prevention or correction 
of the many possible complications is as 
important as the chemotherapy. X-ra- 
diation, of course, has a place in the 
management of these patients particu- 
larly when fractures have occurred and 
produced a significant amount of pain 
in certain areas of the spine. Certain 
orthopedic measures such as providing 
these patients with supportive braces 
help significantly in minimizing pain 
and facilitating the mobilization. Treat- 
ment of the infection and correction of 
the anemia are effective measures. 

What can one expect from this type 
of therapy? I would say that approxi- 
mately 40 to 50 percent of patients with 
myeloma will have a very significant 
decrease in the size of tumor mass, if 
the size of the tumor mass be gauged 
by the amount of abnormal protein pro- 
duced. It has been said that quantitat- 
ing the concentration of this abnormal 
protein in the plasma provides a way to 
follow these patients : 40 to 50 percent 
of patients treated for myeloma with 
this combination will show a decrease 
in this abnormal protein by at least 75 
percent and another 20 percent will de- 
crease by as much as 50 percent, there- 
by, showing partial response. 

When a response of this nature oc- 


May, 1974— Vol. 126, No. 5 


169 


MEDICAL GRAND ROUNDS — Touro Infirmaiy 


curs, one might expect survival for about 
30 months. In the absence of such re- 
sponse, usually these patients die very 
rapidly within a period of a few months 
to a year or so. 

Dr. Jacobs: On the dietary order was 
listed 20 grams of high quality protein. 
When beef and eggs are expensive and 
scarce, what sort of protein should we 
tell people to eat at home ? 

Miss Debra Joseph Besides meat, 
there is none. I would encourage her 
to eat anything that she really wants 
or has a taste for. 

Miss Patricia Caldwell As in meat, 
milk has the best quality of protein. 

Dr. Beltran: Since the cause of the 
uremia of this patient was extrinsic, after 
correction of dehydration and hyper- 
calcemia, one doesn’t really need a great 
deal of protein here. Since you are very 
concerned with hypercalcemia, remem- 
ber that milk is an excellent source of 
calcium, so don’t give her milk. 

Dr. Le Roy Morgan I can’t suffi- 
ciently emphasize the menace of hyper- 
calcemia not only in multiple myeloma 
but also in malignancy which affects 
bone in any way. This applies whenever 
excess hormones cause the release of 
calcium from the bone with resorption 
of the bone. People who suffer bone 
pain should be put in rocking chairs and 
just allowed to rock if they can’t walk 
about. It is amazing to see the diuresis. 
And, of course, the use of 1,000 cc of 
phosphate buffer over an eight hour 
period in someone who has good kid- 
neys will work a dramatic response on 
calcium and promote hydration. Plasma 
cells derived from stem cells are very 
sensitive to alkylating agents but are not 
so sensitive to the antimetabolite type of 
drugs. Alkeran is a phenylalanine de- 
rivative with mustard attached to it and 


Staff dietitian, Touro Infirmary. 

Staff dietitian, Touro Infirmary. 
<j)Consultant in Oncology, Touro Infirmary; 
Associate professor of pharmacology, LSU School 
of Medicine. 


does not need to be activated as does 
Cytoxan. In the past, multiple myeloma 
was treated empirically with either Cy- 
toxan or Alkeran. We have recently 
found that some people don’t respond 
to Cytoxan because their plasma cells 
are fairly primitive and do not contain 
much alkaline phosphatase. Cytoxan 
needs to go through at least three states 
of activation before it can interact with 
DNA. In contrast, Alkeran does not, 
and is, therefore, a better drug for em- 
pirical therapy. However, Cytoxan is 
safer for a patient with severe bone mar- 
row depression or severe platelet depres- 
sion, because it is not quite so throm- 
bocytopenic as is Alkeran or melphalan. 
Prednisone interferes at another spot in 
the cell generation cycle and is useful 
in combination therapy. A drop in the 
protein does not necessarily mean a fa- 
vorable response. This patient’s pro- 
teinuria dropped by 50 percent possibly 
because her liver is making less protein 
as a result of malnutrition or as a result 
of infiltration in the liver of the plasma 
cells. 

Dr. Jacobs: Is the family fully aware 
of the gravity of the situation and do 
they understand the plan you have pre- 
sented to them for treatment? 

Dr. Alfaro: Yes, sir. One sister ac- 
companies the patient most of the time. 
I have explained it to her but I doubt 
very much that she understands the full 
extent of the situation. I talked to the 
patient’s son who is in the Merchant 
Marine, when he came to see her last 
week, and I got the impression that he 
understood the real situation. 

Dr. Jacobs: Did you interpret it to 

them as being a form of cancer? 

Dr. Alfaro: Yes, I did. 

Editor’s Note: The 70-year-old woman 
with backache is most likely to be suf- 
fering from osteoarthrosis or from osteo- 
porosis, but she may be a victim of mul- 
tiple myeloma. We can’t depend on a 
dipstick test of the routine urinalysis 
to detect the Bence-Jones paraprotein; 


170 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Touro Infirmary 


more complicated testing is needed. 
Multiple myeloma is no longer a hope- 
less or an untreatable disease. Both the 
length and the quality of life can be en- 
hanced by appropriate therapy; hence 


there is the need for diagnostic search. 
Terminal acute myelomonocytic leu- 
kemia may develop among patients 
treated for multiple myeloma with mel- 
phalan and cyclophosphamide. 



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By LEON M. LANGLEY, JR. 


This Year Patients Will Spend 8 Percent More for Physicians* Services than they did 
in 1973, predicts the U. S. Department of Commerce in its annual forecast of 
the “Health and Medical Services Industry.” Last year the physicians* charges 
amounted to $18.4 billion, but for 1974 the government agency thinks the fig- 
ure will rise by $1.5 billion. Money spent for hospital care showed the biggest 
percentage increase from 1973 to 1974 with a 10 percent rise — ^the largest for 
all major items in the health care dollar — with the percentage increase for pay- 
ment to physicians the second largest. Commerce Department economists have 
also forecast the annual growth rate for health care expenditures until 1980 and 
again, percentage increases (compounded annually) for hospital costs are the 
highest ranging from an annual “low” forecast of 10.2 percent to a “high” of 
12.1 percent. 

Recently the IRS Ruled That Legally Performed Vasectomies and Abortions were 
eligible for medical expense deductions. Now the IRS has extended this deduc- 
tibility to tubal ligations. Revenue Ruling 73-603 holds that a taxpayer’s costs 
for an operation “legally performed on her at her request to render her incapa- 
ble of having children” are deemed to be deductible as a medical expense, since 
the operation affects “the structure or function of the body.” 

A Recent Study of Prescription Drug Payments Predicts that 60 percent or more of 
pharmacy receipts may be paid by “third parties” in the 1980s. Furthermore, 
third party payments will substantially increase from the present 18 percent 
during the 1970s due to proposed changes in the Medicare and Medicaid pro- 
grams, the advent of national health insurance, and the recent passage of health 
maintenance organization (HMO) legislation. These predictions come from a re- 
port titled “Pharmaceutical Payment Plans — An Overview,” prepared by Jordan 
Braverman, director of Policy Research for the Pharmaceutical Manufacturers 
Association (PMA). The study concludes that “drug supply should no longer be 
considered a distinct and separate service apart from the health care field, but 
rather as an element upon which the costs and utilization of other health services 
are integrally and uniquely dependent.” 

The Nation Spent $94.1 Billion for Health Care in fiscal 1973, up 11 percent from 
fiscal 1972. It was the lowest rate advance in several years, the Social Security 
Administration reported. The Gross National Product rose 10.9 percent in fis- 
cal ’73 and health spending remained 7.7 percent of the GNP. Health spend- 
ing per person averaged $441. Direct payments averaged $132, $9 more than 
in fiscal ’72. Private health insurance paid 26 percent of personal health bills 
and government paid 38 percent. Spending for hospital care rose 10.7 percent. 
Spending for physicians’ services increased 8.5 percent. 

The Great Majority of Washington, D. C. area residents are satisfied with their med- 
ical care. A recent survey showed that 49 percent of those interviewed were 
very satisfied and 37 percent pretty satisfied. The remaining breakdown was 
7 percent not too satisfied, 3 percent not at all satisfied, and 5 percent don’t 
know. The survey, conducted by the Bureau of Social Sciences Research, cov- 
ered 1,209 people in the Washington. D. C. area. 


May, 1974— Vol. 126, No. 5 


173 



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Nurse Practice Act 


The medical profession has been asked 
to assist the Louisiana Nursing Associa- 
tion which expresses deep concern over the 
possible repeal or amending of the Louisi- 
ana Nurse Practice Act. 

Currently there are 18 nurse teaching 
programs accredited by the Louisiana 
State Board of Nursing Examiners. These 
schools are designed to qualify prospective 
candidates to become registered nurses. 
The prescribed courses of instruction in 
each institution, 15 state supported, 3 pri- 
vate, are designed to produce as an end 
product a competent nurse. All graduates 
of an accredited school of nursing in Lou- 
isiana receive temporary permits to prac- 
tice nursing pending the taking of a stan- 
dard written examination. If a candidate 
is successful, the applicant is licensed as a 
registered nurse. Nurses previously li- 
censed as RNs in states other than Louisi- 
ana, upon application, are issued a tem- 
porary permit. If the review of the ap- 
plicant’s credentials is in order, then a 
permanent license is issued. Foreign grad- 
uates are not granted reciprocity, and the 
taking of the written examination is re- 
quired. In 1973, 85.3 percent of Louisi- 
ana educated applicants passed the ex- 
amination at the first sitting; however, 
88.2 percent of the foreign graduates 
failed the same examination. On repeat- 
ing the examination, 65.8 percent failed. 
The language barrier, as well as differ- 
ences in the course of instruction, is of- 
fered as an explanation for the high fail- 
ure rate of the latter group. 

The nursing association’s concern fo- 
cuses on the fact that repealing or amend- 
ing the present law would result in lower- 
ing the present high standards of nursing 
education. The association is fearful that 
should licensure by the state be changed 
that one alternate that would be proposed 
would be the “institutional licensure” of 
nursing personnel. This poses many prob- 


lems in the uniformity of instruction and 
course requirements, and the fear is ex- 
pressed that unqualified nurses would 
then enter into the care of patients in Lou- 
isiana hospitals. Further concern is ex- 
pressed that the impetus to change the law 
is prompted by the desire of hospital ad- 
ministrators to wrestle licensure from the 
control of the nursing association. 

In an attempt to evaluate the underlying 
impetus to change the present system, con- 
ferences with legislators, nurses, hospital 
administrators, physicians and nurse edu- 
cators were conducted. Each was con- 
cerned about the marked shortage of 
nurses, shortages of qualified nursing 
school faculty, shortages of applicants to 
existing schools, and finally what effect 
these shortages have had on the delivery 
of quality health care at the bedside level. 
Some of the discussions pointed out inher- 
ent problems with the present law, prob- 
lems of “poor geographic mobility of an 
RN,” “deficiencies” inherent to any licens- 
ing of professional persons, salary prob- 
lems, and concern that too many “non- 
patient duties” were imposed by hospital 
administrators and directors of nurses on 
the RN. Regardless of which viewpoint a 
spokesman represented, each felt some 
frustration that the situation was not be- 
ing improved by present programs. Each 
felt that the responsibilities for the pres- 
ent shortages were complex; yet, each felt 
that each of them must bear his share of 
fault and responsibility whether he or she 
was a member of the State Board of Nurs- 
ing Examiners, a hospital administrator, a 
member of a nursing society, or a physi- 
cian. Each felt that the legislature was 
now interested in new legislation only be- 
cause the above groups abdicated their re- 
sponsibilities. Each spokesman felt that 
the time had arrived whereby these re- 
sponsibilities should again be recognized 
and assumed by the medical community. 


May, 1974— Vol. 126, No. 5 


175 


EDITORIAL 


The legislators involved in the discus- 
sion urged an appropriate solution engi- 
neered by the medical, nursing and hos- 
pital groups. They advised repeatedly that 
the medical community should present 
any legislation to be considered rather 
than have such legislation originate from 
other sources. 

It is imperative that we produce from 
our ranks the leadership necessary to 
amalgamate the factions involved, and to 
dispel any mistrust which exists in the 


ranks. Supporting the nurses’ association, 
which we will do, is not in itself the solu- 
tion. A method to alleviate the acute 
shortage of competent nurses is, however, 
a solution acceptable to all but most of all 
to the sick hospitalized patient. Frag- 
mentation of the medical community can 
only result in injury to all concerned, 
introducing conflict, resentment, and 
“wounds” that will allow the entrance of 
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176 


J. Louisiana State M. Soc. 



a 


r^atuzaiion 


tii 


^ecti 


on 


The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


SYNOPSIS 

MINUTES 

LOUISIANA STATE MEDICAL SOCIETY 
EXECUTIVE COMMITTEE 
New Orleans, Louisiana 
March 28, 1974 

Confirmation of Mail Vote 

Approval — Minutes of Executive Committee 
12/20/73. 

Approval — Minutes of Educational and Re- 
search Foundation 12/20/73. 

Approval — Active, active dues-exempt and 
intem/resident membership. 

Approval — Proposed Seminar on Drug Abuse 
and Confidentiality (Postponed due to lack of 
registrants primarily because of energy crisis). 

Approval — LSMFP Claim Form for submission 
to Louisiana Insurance Commissioner for en- 
dorsement (See Reports and Action Taken). 

Approval — Report of Committee on Budget 
and Finance (contains recommendation for in- 
crease in dues — to be submitted to House of 
Delegates) . 

Reports 

President — Meetings recently attended; pres- 
entation of study report by Dr. Edward Hjmian 
in re drugs (See Action Taken) ; suggested reso- 
lution of congratulations to Dr. Charles Mary for 
his stand in re Family Health Foundation (See 
Action Taken) ; discussion of matters unfinished 
during term in office. 

Secretary-Treasurer — LSMS and AMA mem- 
bership; honorary membership for Dr. George H. 
Hauser (See Action Taken) ; Annual Meeting 
plans; Distinguished Service Award for Dr. C. 
Grenes Cole (See Action Taken). 

Board of Councilors — Cases considered during 
past year resolved; additional cases to be consid- 
ered after this meeting. 

Council on Socio-Economics — Seminars for in- 
terns and residents; Professional Liability Insur- 
ance plans; Errors and Omissions Insurance pol- 
icy purchased. 

Committee on Areawide Planning — Recommen- 
dation in re resolution in opposition to content of 
HR 12053 (See Action Taken). 

Committee on Arrangements — 1974 Annual 
Meeting — proposed budget (See Action Taken). 


Committee on Charter, Co'nstitution and By- 
Laws — proposed amendments (See Action 
Taken). 

Committee on Environmental Health — report of 
presentation in re application of Mirex. 

Committee on Journal — continuation of profes- 
sional cards (See Action Taken). 

Committee on Long Range Planning — recom- 
mendations presented in resolution from 1973 
House of Delegates meeting (See Action Taken). 

Committee on LSMFP and Health Insurance — 
amendment to LSMFP Form; possible endorse- 
ment by Louisiana Insurance Commissioner (See 
Action Taken). 

Committee on Mental Health — proposed legisla- 
tion (See Action Taken). 

AMA Delegates — proposed resolutions; action 
taken at December clinical meeting. 

Legislative Consultant — Conference on Quack- 
ery; proposed bills for introduction in Legisla- 
ture. 

Legal Counsel — opinions rendered; proposal in 
re Professional Liability Review (See Action 
Taken). 

Woman's Auxiliary — activities of Auxiliary. 

Communications 

Orleans Parish Medical Society in re insurance 
programs available to members. 

South Central Bell in re listing of physicia'ns 
in yellow pages. 

Lt. Governor in re reappointment of Dr. J. 
Morgan Lyons to State Board of Medical Ex- 
aminers. 

Dr. F. Michael Smith in re Current Effects on 
Hospital Economics, etc. 

Tulane University School of Medicine — thanks 
for contrihution from ERF to library. 

LSU Shreveport — ^thanks for contrihution from 
ERF to library. 

Medical Association of Georgia in re PSRO 
activity. 

American College of Radiology ineeting in New 
Orleans. 

Dr. R. Pierce Foster in re PSRO film and Hos- 
pital Staff By-Laws (Personal opinion — not opin- 
ion of Rapides Parish Medical Society). 

Lafourche Parish Medical Society in re PSRO 
policy of that society. 


May, 1974— Vol. 126, No. 5 


177 


ORGANIZATION^ SECTION 


JCAH Material from Dr. Kurzweg — submitted 
by Shreveport Medical Society (See Action 
Taken). 

Omaha Medical Society in re activity concern- 
ing PSRO. 

Medserco Incorporated in re Government inter- 
ference in medical care. 

Dr. F. Michael Smith — recommendation con- 
cerning introduction of resolution on PSRO in 
Louisiana Legislature. 

Dr. C. Elmo Boyd and Dr. F. Michael Smith — 
Utah Peer Review Organization. 

Action Taken 

Recommendation of Committee on Areawide 
Planning adopted; The LSMS Executive Commit- 
tee draft resolution for presentation at 1974 An- 
nual Meeting of LSMS in opposition to content 
of HR 12053 as it stands at present time. Agreed 
to send copy to AMA. 

Proposed budget submitted by Committee on 
Arrangements for 197 U Annual Meeting ap- 
proved. 

Recommendation of Committee on Budget and 


Finance in re increase in dues — to be submitted 
to House of Delegates. 

Proposed amendments recommended by Com- 
mittee on Charter, Constitution and By-Laws to 
be submitted to House of Delegates: 1. Change 
congressional districts to medical districts (re- 
ferred to Committee by House of Delegates) ; 
approved. 2. Addition of Board member of 
LAMPAC to Executive Committee of LSMS (re- 
ferred to Executive Committee by House of Dele- 
gates and referred to Committee on Charter, 
Constitution and By-Laws by Executive Commit- 
tee) ; Amendment not approved; Chairman of 
LAMPAC to continue to receive an invitation to 
attend meetings of Executive Committee. 3. Pro- 
vide dues-exempt membership for those regular 
members of LSMS who have reached age seventy 
(referred to Committee by Executive Commit- 
tee) ; approved. 4. Transmittal of LSMS and 
AMA dues from component societies to LSMS 
(referred to Committee by Executive Commit- 
tee) ; Statement “without delay” approved. 5. 
Amendment for special membership for oral sur- 
geons (referred to Committee by Executive Com- 
mittee) ; Recommendation that no change be made 


At Your Service in 
The Pelican State 


In the region* named by LaSalle 
in honor of Louis XIV and 
sometimes called The Creole 
State because of its many 
descendants of early French and 
Spanish settlers . . . 



PHARMACEUTICAL DIVISION 

MARION 

LABORATORIES. INC. 

KANSAS CITY, MO. 64137 


is represented by . . . 



John Able 


Dick Sensat 



Dennis Spencer 




Terry Whitney 



Harry Wilder 


These men bring you 



178 


J. Louisiana State M. Soc. 



ORGANIZATION SECTION 


to specifically accommodate oral surgeons ap- 
proved. 

Proposed legislation for confidentiality and 
privileged communication for psychiatrists and 
their patients; action deferred pending additional 
legal opinion. 

Professional Liability Review, including pro- 
posed amendment to By-Laws, submitted by legal 
counsel ; approved for submission to House of 
Delegates. 

Amount of $10,000.00 to be made available for 
anti-PSRO activity spending-, subject to review 
by Executive Committee. 

Recommendation of Joumial Committee that 
professional cards be continued at double pre- 
vious charge approved. 

Information concerning JCAH to President of 
Shreveport Medical Society and members of this 
Executive Committee. 

Participation on an amicus curiae basis in suit 
filed in federal court by Association of American 
Physicians and Surgeons challenging the PSRO 
law approved if can be done for reasonable 
charge. 


Course for physicians on Transactional Analy- 
sis — referred to Committee on Mental Health. 

Opposition to repeal of anti-substitution drug 
bill. 

Recommendation that Executive Conamittee in- 
stitute non-sanction of proposed surveys regard- 
ing ambulatory health care services endorsed. 

Study report concening drugs prepared by Dr. 
Edward Hyman — endorsed with proviso that 
opening remarks be deleted. 

Congratulatory resolution or letter to be sent 
to Dr. Charles Mary in re his stand with regard 
to Family Health Foundation at appropriate 
time. 

Recommendation of Honorary membership for 
Dr. George H. Hauser to be submitted to House 
of Delegates. 

Secretary-Treasurer authorized to appoint 
delegates to represent medical schools, intern/res- 
ident group and medical students in House of 
Delegates when recommendations are received 
from groups involved. 

Recommendation of Dr. C. Grenes Cole as re- 
cipient of Distinguished Service Award to be sub- 
mitted to House of Delegates. 



Puts comfort 
in your prescription 
for nicotinic acid 



May, 1974— Vol. 126, No. 5 


179 


ORGANIZATION SECTION 


A powerful lot of people 
have been saving at 
Eureka since 1884 



2525 Canal Street Phone 822-0650 
110 Belle Chasse Hwy. 

West Bank Division 
EUREKA HOMESTEAD SOCIETY 


Assista7it Secretary-Treasurer to continue as- 
sociation with LSMS on a co7isultant basis with 
an additional amount for expenses, at time of 
her retirement. 

Recommendations of Committee on Long Range 
Planning, as follows, to be submitted to House 
of Delegates: 1. Title of Executive Vice-Presi- 
dent be added to that of Secretary-Treasurer 
with no significant changes in duties. 2(a). 
Whenever possible LSMS committee meetings be 
scheduled far in advance and meeting dates be 
published in JLSMS. 2(b). Consideration be 
given to appointment of committee members from 
the same area in order to secure better atten- 
dance at committee meetings. 3. Executive Com- 
mittee and Council on Legislation, through what- 
ever mechanism necessary, secure legislation that 
would offer legal protection for more effective 
internal review; suggest reports of hospital re- 
view committees be sent to LSMS Division of 
Socio-Economics for study and analysis. 4(a). 
Following each meeting of Executive Committee, 
each Councilor send a Councilor Repoi't to all 
members in his district; LSMS staff responsible 
for printing and distribution. 4(b). In addition to 
publication in JLSMS of synopsis of minutes of 
Executive Committee meetings and House of 
Delegates meetings, brief narrative report cover- 
ing highlights be published in JLSMS. 4(c). In- 
vitation be extended to parish medical society 
presidents to attend Executive Committee meet- 
ings as observers. 4(d). Members of Executive 
Committee take every opportunity (hospital staff 
meetings, etc.) to report on activities of LSMS. 

Request for endorsement of LSMFP fomn by 
Louisiana Insurance Commissioner deferred until 
further study. 

Proposed Medical Technology Licensure Bill 
not to be supported by LSMS. 

Proposed ame^idments to the State Uniform- 
Controlled Dangerous Substances Law approved 
with certain modifications by legal counsel. 

Other Subjects Discussed 

Membership classifications of component so- 
cieties. 

Legislative matters pertaining to mental health. 

Resigjiation of Chairman of Council on Legis- 
lation and new appointment by President. 

State Office of Comprehensive Health Planning 
contract with HEW in re provisions of Social 
Security Act. 

Resolution in re opposition to HR 12561. 

Next meeting of Executive Committee. 

Action by ERF 

Payment of portion of salary and expe^ises of 
office. 

Purchase of PSRO film not advised by legal 
counsel. 

Fund raising projects suggested. 

J. Louisiana State M. Soc. 




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CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every month 


Calcasieu 

Fourth Tuesday of every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday of every month 

Baton Rouge 

Jackson-Lincoln- Union 

Third Tuesday of every month 
except summer months 


Jefferson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every other month 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

Independence 

Terrebonne 

Third Monday of every month 


Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday of every month 



THE LOUISIANA CAMP FOR DIABETIC 
CHILDREN 

YMCA Camp Singing Waters 

Two weeks of the YMCA Camping Season are 
set aside for youngsters with diabetes mellitus 
so that they may enjoy the fun of summer camp- 
ing. In addition to the regular YMCA staff, this 
session is supervised by physicians, nurses, dieti- 
tians and laboratory technicians with a special 
interest in diabetes. The primary goal of this ses- 
sion is to provide the diabetic child with a camp- 
ing experience under medical supervision. Activi- 
ties are planned so that the possibilities of insulin 
reactions are greatly minimized. Canoeing, horse- 
back riding, archery, crafts, riflery, fishing and 
many other fun-filled activities are available. 

Camp will begin on Sunday, July 21, 1974 and 
close on Saturday, August 4, 1974. 

Camp Singing Waters is located in Livingston 
Parish at Holden, Louisiana. The camp is 30 miles 
east of Baton Rouge and 12 miles west of Ham- 
mond on Highway 190. The 75-acre site includes 
a lake and lagoons and is located next to the 
Tickfaw River. 

The camp is a non-profit operation. Many of 
the services provided are voluntary. Many of the 
supplies are donated. The actual cost of the two- 
week camping period amounts to $185.00 per 
child. A registration fee (non-refundable) of 
$25.00 must accompany the application and will 
be credited toward the camp fee. Assistance will 
be offered to those parents who are unable to 


pay the camp fees. Children aged 8-14 are 
eligible to apply. 

For application forms and further information, 
please call or write the Diabetes Association of 
Greater New Orleans, 606 Common St., New Or- 
leans, Louisiana 70130. (504) 524-H-E-L-P. 


20th ANNUAL SOUTHERN OB-GYN 
SEMINAR 
JULY 21-26, 1974 

The 20th Annual Ob-Gyn Seminar will be held 
again this year in Asheville, North Carolina at the 
Grove Park Inn, July 21 through July 26. 

A wide variety of subjects in obstetrics and 
gynecology will be presented and program par- 
ticipation will include the medical schools of 
North Carolina, Duke, Bowman Gray and the 
Medical College of Virginia, in addition to out- 
standing speakers from other areas. 

For registration information, please contact 
the Secretary, Dr. George T. Schneider, 1514 
Jefferson Highway, New Orleans, Louisiana 
70121. 


1974 TRI-STATE SCIENTIFIC SESSIONS 
FOR PHYSICIANS 
MAY 15-17, 1974 

The 1974 Tri-State Scientific Sessions for phy- 
sicians will be held at the Broadwater Beach Ho- 
tel in Biloxi, Mississippi on May 15, 16 and 17. 
The sessions, entitled “Controversies in Cardi- 
ology,” are co-sponsored by the Arkansas, Lou- 
isiana and Mississippi Heart Associations and the 


182 


J. Louisiana State M. Soc. 


MEDICAL NEWS 


American Heart Association Council on Clinical 
Cardiology. 

For more information contact Mrs. Pat H. 
Roundtree, Program Director, Mississippi Heart 
Association, P. 0. Box 16063, Jackson, Mississippi 
39206. 

Registration fees are as follows: 

$75.00 for Fellows, Associate Fellows and 
Members of the Council on Clinical Cardiology; 
$75.00 for MEMBERS of the Arkansas, Louisi- 
ana and Mississippi Heart Associations, and 
$100.00 for Non-Members. The registration fee 
includes social hour Wednesday, buffet luncheon 
Thursday and Friday and coffee breaks. 

Checks should be made payable to : Mississippi 
Heart Association. 

Refund of fee will be made if cancellation is 
received not later than ten days prior to the 
course. 

The Council on Medical Education of the 
American Medical Association has accredited this 
program. It is acceptable for 12 hours credit 
toward the AMA Physician’s Recognition Award. 

The American Association of Family Practice 
has accredited this program for 12 elective hours. 


AMERICAN BOARD OF FAMILY PRACTICE 

The American Board of Family Practice an- 
nounces that it will give its next two-day written 
certification examination on October 19-20, 1974. 
It will be held in five centers geographically dis- 
tributed throughout the United States. Informa- 
tion regarding the examination may be obtained 
by writing: 

Nicholas J. Pisacano, MD, Secretary 
American Board of Family Practice, Inc. 
University of Kentucky Medical Center 
Annex #2, Room 229 
Lexington, Kentucky 40506 
PLEASE NOTE: It is necessary for each phy- 
sician desiring to take the examination to file a 
completed application with the Board office. 
Deadline for receipt of applications in this office 
is June 15, 1974. 


NOTICE OF WORKSHOPS ON FEDERAL 
DIAGNOSTIC X-RAY STANDARD 

A Federal standard for diagnostic x-ray equip- 
ment becomes effective August 1 of this year. 
This equipment standard primarily applies to 
manufacturers and assemblers but users are also 
affected. 

Because the final standard was extensively re- 
vised and amended since first proposed in 1971, 
it is not surprising that many individuals affected 
are not yet knowledgeable about its full implica- 
tions. 


Linder the standard, x-ray manufacturers are 
responsible for producing equipment and compo- 
nents that perform according to requirements of 
the standard. Assembler’s primary responsibility 
is to install the system according to the manu- 
facturer’s specifications and to use the type of 
components called for by the standard. He must 
certify that these two conditions have been met 
by filing specified forms with the Food and Drug 
Administration’s Bureau of Radiological Health, 
the State Radiation Control Agency, and the 
purchaser. 

One of the principal protection provisions of 
the standard requires machines to be capable of 
restricting the x-ray beam to the size of the film 
or fluoroscopic image receptor. The standard also 
contains provisions intended to make it possible 
for operators to reproduce more consistently a 
given image quality for given voltage, current, 
and time settings. This capability, in combination 
with good x-ray examination techniques, will tend 
to minimize film retakes and unnecessary ex- 
posure. 

To familiarize persons who are affected by the 
new standard, especially commercial installers and 
users who may perform their own installations, 
with their responsibilities under the new regula- 
tions, workshops are being conducted by the Food 
and Drug Administration. These one-day sessions 
are being held in various parts of the United 
States. Persons interested in attending are urged 
to contact the FDA Radiation Control Officer in 
their region for additional information. Work- 
shops will also include discussions of proposed 
Federal requirements involving resale of used 
x-ray equipment. 

For Louisiana, the Control Officer is: Paul A. 
Dickson, Room 470B, 500 South Ervay Street, 
Dallas, Texas 75201. Telephone (214) 749-2225. 


AMERICAN COLLEGE OF CARDIOLOGY 
ELECTS NEW OFFICERS 

Charles Fisch, MD, Indianapolis, Ind., was 
chosen President-Elect of the 5,800-member 
American College of Cardiology at the 23rd An- 
nual Scientific Session of the medical specialty 
society held February 11-14 in New York City. 
He will take office in 1975, succeeding Henry D. 
McIntosh, MD, Houston, Tex., who was inducted 
as President at the Annual Convocation cere- 
mony. 

Dr. Fisch is Professor of Medicine and Direc- 
tor of the Cardiovascular Division at Indiana 
University School of Medicine. He is a former 
President of the Indiana Heart Association. 

Others elected to office, to begin their terms 
immediately, were: Dean T. Mason, MD, Davis, 
Calif. ; David C. Sabiston, Jr., MD, Durham, N.C. ; 
and Sylvan L. Weinberg, MD, Dayton, O. — all 


May, 1974— Vol. 126, No. 5 


183 


MEDICAL NEWS 


Vice Presidents; and Robert J. Hall, MD, Hous- 
ton, Tex., Assistant Secretary. 

Re-elected were: James E. Crockett, MD, Kan- 
sas City, Mo., Secretary; John J. Curry, MD, Sil- 
ver Springs, Md., Treasurer; and Edward W. 
Hawthorne, MD, Columbia, Md., Assistant Trea- 
surer. 

Chosen to serve a five-year term as Trustee of 
the American College of Cardiology was John L. 
Ochsner, MD, New Orleans, La. He is to begin 
his term of office immediately. 


OSTEOSARCOMA REFERRALS REQUESTED 

Cooperation of physicians is asked in referral 
of patients with operable bone or soft tissue 
sarcoma to the Surgery Branch, National Cancer 
Institute, to enter into a randomized study of 
Warfarin anticoagulation and chemotherapy as 
adjunctive measures to surgical treatment . 

Patients must have no evidence of metastatic 
disease and must not have received chemotherapy, 
radiotherapy, or surgery to the primary site ex- 
clusive of biopsy or minimal local resection. 

Physicians interested in further details and in 
having their patients considered for admission 
may write or telephone: 

Admiting Office 
National Cancer Institute 
Clinical Center, Room 1 ONI 19 
National Institutes of Health 
Bethesda, Maryland 20014 
Telephone: 301-496-2031 


COMMITTEE CITES MINIBIKE DANGERS 

The American Academy of Pediatrics’ Joint 
Committee on Physical Fitness, Recreation, and 
Sports Medicine has urged parents to “hold firm 
in their refusal to allow their children the in- 
escapable risk-taking involved in owning and/or 
operating a minibike.” 

In a statement on minibike safety, the Joint 
Committee said: “The trend toward allowing 
underage children to operate minibikes should be 
deplored and condemned. This would be indicated 
on general principles even if the minibike were a 
quasi-safe vehicle, which it most emphatically is 
not.” 

The statement said minibikes are particularly 
dangerous because of: poor handling due to a 
short wheelbase and small tires; insufficient ac- 
celeration; inadequate brakes; small size, which 


decreases visibility; and inadequate protection of 
drivers against collision. 

The Joint Committee said that an estimated 
two million minibikes are in operation in the 
United States, most of them driven by children 
10 to 14 years of age. 


MEETING ANNOUNCEMENT 

A two-day clinical symposium for physicians on 
“Management of Life-Threatening Problems in 
the Emergency Department” will be held at the 
Hilton Inn, Tulsa, on June 6 and 7, 1974. The 
meeting will be sponsored by Saint Francis Hos- 
pital, Tulsa; the American College of Surgeons 
Oklahoma Trauma Committee ; the Oklahoma Di- 
vision of the American Trauma Society; and the 
Oklahoma Trauma Research Society. Enrollment 
fee is $75 which includes luncheons and recep- 
tion. Interested physicians should contact the 
Oklahoma Trauma Research Society, Suite 811, 
6565 S. Yale, Tulsa, Oklahoma 74136. Phone 
(918) 663-1577. 


AMERICAN SOCIETY OF CLINICAL 
HYPNOSIS 

A component society of the American Society 
of Clinical Hypnosis is being formed in the 
Greater New Orleans area. The officers, which 
were elected at an organizational meeting on 
March 5, 1974 were: Dabney Ewin, MD, Presi- 
dent; Jeannette K. Laguaite, PhD, Secretary- 
Treasurer. 

Persons interested in joining may contact the 
President at 914 Union Street, New Orleans, 
Louisiana 70112. 


JAMES H. SAMMONS, MD, TO BE AMA 
EXECUTIVE VICE PRESIDENT 

The Board of Trustees of the American Medi- 
cal Association has announced the appointment 
of James H. Sammons, MD, as Executive Vice 
President-designate. 

The post of Executive Vice President is the top 
administrative position at the AMA. Doctor Sam- 
mons will succeed Ernest B. Howard, MD, who 
has been EVP since March 1969. Doctor Howard 
will reach retirement age early next year. 

Doctor Sammons, a family physician in Bay- 
town, Texas, became chairman of the AMA 
Board of Trustees in October, 1973. Previously he 
had served as its vice chairman for one year. 




184 


J. Louisiana State M. Soc. 


Have you ever held a meeting 
between a Riverboat and a Southern Plantation? 



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1000 room, 42 floor 
New Orleans Marriott 
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Quarter ! Where the 
lobby’s a Southern 
Plantation fantasy; the 
rooftop’s an old-time 
Mississippi Riverboat 
restaurant; and you’re 


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facilities are as fabulous 
as our meeting facilities ! 

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May, 1974— Vol. 126, No. 5 


185 






euiews 


Current Pediatric Diagnosis and Treatment; by 

C.H. Kempe, H.K. Silver and D. O’Brien. Ed 2, 

Lange Medical Publications, Los Altos, Cal., 

1972, $12. 

This is an excellent reference book for the 
pediatrician. It is unfortunate that it is not in 
hard cover because after being used a short 
time it will not hold up in its present flexible 
paper cover. 

The chapters on history taking and history 
sheets are exceptionally good. The chapters on 
neuromuscular disorders, pediatric psychology 
and genetic and chromosone disorders are good 
and new. 

Simple tips like removing gum with peanut 
butter and tar with ice are practical little pearls 
. . . hints from “Heloise” for the pediatrician. 

Edrisal, which the authors recommend and 
which I have used successfully, has now been 
taken off the market by the FDA, so even by 
consulting the newest publications it is difficult 
to keep up with the drug picture. 

This book has some information in it which 
is not included in other references, but in gen- 
eral it is still just another reference book. 

Suzanne Schaefer, MD 


Review of Medical Pharmacology, F. H. Meyers, 
E. Jawetz and A. Goldfien. Ed. 3. Lange 
Medical Publications, Los Altos, Cal., 1972, 
$8.50. 

In that this is the third edition, this presen- 
tation is an obvious commercial success. The title 
implies that individuals who buy this volume 
have some past experience in pharmacology. If 
there were a way to ensure that this is true, it 
would be a good way to review the subject. Un- 
fortunately, I feel that the majority of people 
who buy it are taking the course for the first 
time. 

The reason for my concern is that, of neces- 
sity, to cover the material in the manner of a re- 
view, the authors must summarize a great deal 
of material. In the process, they must use their 
own priorities with regard to that material which 
should be retained and that which should be 
eliminated. In so doing they may get carried 
away and eliminate some basic points which are 
really needed for complete understanding. 

With these foregoing doubts in mind, I would 
like to say that the authors have been able to 
present a large amount of information in a clear 
manner. They have presented it in a new per- 
spective and given it their own interpretation. 


The consistency with which they attain their 
stated objectives, eg, little emphasis on chemical 
structure, makes one wonder whether any in- 
dividual was responsible for maintaining con- 
tinuity throughout. My feeling is that this vol- 
ume would be valuable to practicing pharmacists 
as a review of the area of pharmacology. 

Floyd R. Domer, PhD 


Teeth, Teeth, Teeth, by S. Garfield, DDS. Simon 

and Schuster, New York, 448 p, 1969, $9.95. 

This is a treatise on teeth and related parts 
of man, land and water animals from earth’s 
beginning to the future of time. 

The book presents very interesting reading 
generally throughout. It should be kept in mind 
that it is the work of a single individual whose 
ideas need updating in many instances and are 
far-out in many others. 

It is obviously well researched and documented 
in certain aspects; it is opinionated and ficticious 
in other aspects. 

R. C. Coker, DDS 


Square Pegs, Round Holes; by Harold B. Levy, 

MD. Little Brown and Co., 1973, 250 p, $7.50. 

This book is an attempt to give parents, teach- 
ers and other professionals an understanding of 
children whose learning problems stem from min- 
imal brain dysfunction. The author’s interest 
and concern for these children and their parents 
are evident; however, the book is disappointing 
because of its narrow scope, and it is overloaded 
with disparaging statements concerning the con- 
tributions of other workers. 

Dr. Levy ascribes the cause of minimal brain 
dysfunction to “a biochemical imbalance” without 
acknowledging the complexities and uncertainties 
in the present state of our knowledge, and he is 
overly enthusiastic in his presentation of long- 
term drug treatment for children with minimal 
brain dysfunction. There is no acknowledgment 
of the fact that most investigators report that 
methylphenidate is helpful for only about 50 per- 
cent of children with M.B.D. Those who warn 
of side effects and dangers are denounced, and 
it is implied that all who do not share the 
author’s enthusiasm for the use of stimulants are 
uninformed radicals comparable to those who 
oppose such public health measures as fluorida- 
tion of water supplies. Presumably, this would 
include Richmond Paint, John Werry, Mark Stew- 
art and members of the multidisciplinary Presi- 
dent’s commission who recommend cautious use 
of stimulants, primarily as a temporary expe- 


186 


J. Louisiana State M. Soc. 


BOOK REVIEWS 


dient to tide children over crises. Dr. Le^’y, on 
the other hand, states that some children need 
to take them “through high school and on to 
college.” He gives testimonials concerning the 
effectiveness of methylphenidate and imipramine 
but says nothing about the scarcity of well con- 
trolled studies. 

The author does not make clear how he dis- 
tinguishes between the child with minimal brain 
dysfunction and other children with similar clin- 
ical features whose restlessness and other diffi- 
culties are the result of anxiety or depression. He 
apparently recognizes only two sources of aca- 
demic difficulty: minimal brain dysfunction and 
stubbornness. Emotional problems are mentioned 
only as consequences of learning problems, never 
as their cause. 

Dr. Le\'y summarily dismisses the work of be- 
havioral scientists. He states, incorrectly, that 
“They offered an explanation for all educational 
disorders on the grounds of emotional maladjust- 
ment.” It is regrettable that he did not present 
more fully the concept of minimal brain dysfunc- 
tion and its management rather than devote so 
much space to sarcastic criticism of child workers 
in the fields of education, psychology*, psychiatry 
and psychoanalysis. 

Dr. Levy would do well to take his own advice 
“to step back and try to picture the whole 
problem.” 

Lilliax H. Robinson, MD 


The Crisis Team: A Handbook for the Mental 

Health Professional-, by Julian Lieb, Ian I. 

Lipsitch, and Andrew Slaby. Harper and Row, 

1973, 186 p, S6.95. 

Over the course of the past decade there has 
been a burgeoning interest in the technique of 
crisis intervention. The techniques of crisis inter- 
vention are generally active and directly address 
the immediate presenting problem of the patient, 
utilizing any and all appropriate measures from 
environmental manipulation through analytically 
oriented interpretation to administration of psy- 
chopharmacological agents. Our knowledge about 
crisis states, their cause, management and appro- 
priate disposition once the crisis has passed has 
grown rapidly probably primarily as the result 
of the experiences of the personnel in the numer- 
ous mental health clinics throughout the LTnited 
States. 

The authors present a succinct, balanced and 
thorough overview of the subject of the crisis 
team and the integration of this team in manag- 
ing a patient who is experiencing a life crisis. It 
is a distinct and worthwhile contribution to the 
growing body of publications of this area. Al- 
though somewhat at variance with previous clas- 
sical concepts of crisis, the authors offer a quite 


pragmatic definition of the crisis patient whose 
presentation generally falls into nine groupings. 
The crisis team and the roles of its members are 
carefully defined as well as the structure of the 
crisis unit and its relationship to its referral 
sources. The gathering of clinical history with 
considerable emphasis (at least in the area of 
the psychotic illnesses) upon traditional phenom- 
enological or descriptive phenomena which still 
provide the bedrock for psychiatric diagnosis is 
carefully outlined. These special problems per- 
taining to the evaluation and to the management 
of the suicidal or homicidal patient are also well 
detailed. 

In effect, this book represents a practicum, 
simple without being simplistic, clearly written 
and pragmatic. Since crisis intervention in its 
variant applications comprises an important as- 
pect of psychiatric practice, The Crisis Team 
should be of considerable value to practicing psy- 
chiatrists, whatever their field of interest and 
orientation may be, as well as to those mental 
health professionals who concentrate in this area 
of specialization. 

Wallace K. Tomlinson, MD 


The Diabetic Foot-, by Marvin E. Levin and 

Lawrence W. O’Neal. G. V. Mosby Co., St. 

Louis, Missouri, 1973, 262 p, §25.50. 

Foot problems are probably the most neglected 
aspect of the management of diabetic patients. 
Proper understanding of prophylactic and thera- 
peutic measures by both physician and patient is 
of utmost importance if problems are to be kept 
to a minimum. The Diabetic Foot is a welcome 
resource for those involved with diabetic patients. 
The contributors included both investigators and 
practitioners from the Washington University 
School of Medicine. The coverage is broad, and 
besides medical and surgical aspects of the dia- 
betic foot, there are chapters on neuropathy, vas- 
cular disease, bacteriology, roentgenography, re- 
habilitation and podiatry. 

The authors emphasize the importance of rou- 
tine examination of the feet in every diabetic 
patient, as well as the difference in the manage- 
ment of diseases of the foot in the diabetic pa- 
tient as compared to the non-diabetic. There are 
some duplications; for example, similar lists of 
rules for home care of the feet are given in two 
different chapters. There are some striking con- 
trasts in the approach to problems. F or example : 
that of debridement as described by the surgeon 
and that described by the podiatrist. Although 
the contributions by podiatrists can be rather sig- 
nificant in the management of diabetic patients, 
I think the chapter on podiatry in this book 
rather overstates the contribution of podiatrists, 
particularly in the area of podiatric surgery. 

Overall, clinicians dealing with diabetic pa- 


May, 1974— Vol. 126, No. 5 


187 


BOOK REVIEWS 


tients will find information concerning the pre- 
vention, diagnosis and treatment of diabetic 
foot problems that is difficult to locate in any 
other one book and as such, The Diabetic Foot 
should be a useful addition to their library. 

Jerome R. Ryan, MD 


Medical Student: Doctor in the Making; by James 

A. Knight, MD. Appleton-Century-Crofts, Edu- 
cational Division, Meredith Corporation, New 

York, 1973, 235 p, $7.95 (paperback). 

The author is admirably qualified to write 
about the vicissitudes of the medical student in 
his four year metamorphosis from layman to phy- 
sician. Dr. Knight’s years of experience in eval- 
uating students for admission, in teaching, and 
in counseling have provided a solid base of first- 
hand observation and knowledge. In addition, his 
training as a minister and psychiatrist provides 
a spiritual and psychological perspective which 
adds depth and richness to his discussion. 

During a typical medical school curriculum, the 
student must not only learn a vast amount of 
factual material, the sheer effort of which tests 
his stamina and dedication, but more importantly, 
he must go through a process of inner growth 
and development which is perhaps unique among 
the professions. The major thrust of the book 
is directed to aspects of that change. These are 
taken up and discussed in chapters devoted to 
problems of professional identity, the student’s 
reaction to the cadaver, sexual and psychological 
problems of medical students, development of tol- 
erance for uncertainty, coming to terms with 
feelings about death, the woman medical student, 
the decision to become a doctor, and the search 
for the ideal medical student. The author iden- 
tifies and examines a number of complex ques- 
tions, but does not attempt to provide specific 
“answers”. 

A medical student who discussed the book with 
me was disappointed that Dr. Knight did not 
take a “positive stand” on certain issues and, in 
effect, tell us how medical faculties, organized 
medicine, or society at large could solve these 
problems by concerted action. I think the student 
missed an important point. The book is about 
how the future doctor, with his own unique per- 


sonality, meets a series of new and often fright- 
ening challenges, and how he copes with them. 
The defects and inadequacies of medical educa- 
tion and the delivery of health services, while of 
vital importance, are subjects for consideration in 
another context. To use an analogy, this book 
is an embryology text rather than a treatise on 
pathology and therapeutics. 

When studying embryology, I had a sense of 
wonderment that such a complex process as the 
nine month development from fertilized ovum to 
living baby so often ends happily. Despite the 
numerous possibilities for things to go wrong, 
there are few dead or deformed babies and so 
many healthy ones. The same is true for medical 
students whose long period of “gestation” is 
fraught with real and potential dangers. A sur- 
prising majority of them come through in good 
shape. Parenthetically, I hope that this fact will 
help to reassure students whose anticipatory 
anxiety may be increased by some of the material 
in the book. Based on personal recollections, I 
am sure that medical students of a generation 
ago were far less aware of the complex problems 
that had to be dealt with, than are the students 
of today. I suspect that awareness may bring 
more conscious anxiety but also may offer better 
ways to deal with the problems and with the 
anxiety. Dr. Knight, for example, emphasizes the 
usefulness of counseling or psychoanalytically 
oriented therapy. I think it is very helpful for 
students to know this and to be less reluctant to 
discuss difficulties and ask for help before minor 
problems grow to serious proportions. 

This is an excellent book. Along with valid, 
detailed information about many aspects of the 
medical student’s experiences. Dr. Knight pro- 
vides a blend of personal observations and his 
own formulations. He writes clearly and grace- 
fully, and appends to each chapter a well selected 
list of references. The book should be of interest 
to all physicians and all who hope to become phy- 
sicians. It will be particularly valuable to those 
who are concerned with the social and psycho- 
logical components of the medical student’s life 
(as we all should be), and to everyone involved 
with medical education and with the selection of 
applicants for medical school. 

Henry H. W. Miles, MD 


188 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


S6.00 Per Annum, SI. 00 Per Copy 771X117 1 QT/1 Published Monthly 

Vol. 126, No. 6 ^ UINXj, 1700 Josephine Street, New Orleans, La. 70113 


Informed Consent: A Right to Know* 


NE of the most difficult and perplex- 
ing legal responsibilities imposed on 
the medical practitioner is the duty to 
obtain informed consent to treat a patient. 
As a result of four recent court decisions, 
the new doctrine of informed consent will 
certainly engender an explosion of litiga- 
tion against medical doctors. 

It all began when Anna Mohr made 
legal history by recovering damages from 
Dr. Williams, who performed an operation 
on her left ear without her consent.^ She 
had consented to an operation on her right 
ear, and the doctor placed her under a gen- 
eral anesthetic. MTiile operating, he found 
the left ear was more severely infected, so 
he performed an operation on it. Compli- 
cations developed on the left side which re- 
sulted in the loss of hearing. In gi’anting 
her recovery, the Minnesota Supreme 
Court said: 

Every person has a right to complete immunity 
for his person from physical interference of 


* Reprinted with permission. Insurance Counsel 
Journal, October, 1973. 

Henry B. Alsobrook, Jr., a pairtner in the firm 
of Adams and Reese, New Orleans, received his 
BA and JD degrees from Tulane University. He 
was the first president of the New Orleans Asso- 
ciation of Defense Counsel, 1965. He is a past 
chairman of the medical-legal committee of DRI 
and is an affiliate member (honorary') American 
Medical Association. His acthdties include ex- 
tensive participation in both the American Bar 
Association and the Louisiana State Bar Associa- 
tion. He also lectures on medical malpractice. 


HENRY B. ALSOBROOK, JR. 

New Orleans 

others, . . . and any unlavTful or unauthorized 
touching of the person of another; except it be 
in the spirit of pleasantry, constitutes an assault 
and battery. 

The problem with the informed consent 
theory is that recovery is not based on a 
showing that the physician was actively 
negligent. In most cases, the physician 
has performed his duty in an adequate 
professional manner, but the patient has 
developed some unexpected complications 
during the course of treatment. Since he 
did not give the patient any information 
concerning this contingency, his “sin” is 
one of omission, ie, failure to inform his 
patient of possible risks inherent in the 
treatment proposed. 

The foundation of the infonned consent 
theory is the same as the general principle 
set forth in the Mohr decision and a later 
decision by Judge Cardozo where he 
stated, “a person has a right to determine 
what will be done with his own body.”- In 
order to give this right some substance, a 
corollary, which had been working in the 
background of many malpractice deci- 
sions, surfaced in Salgo v. Lekind Stand- 
ford, Jr. University Board of Trustees,^ 
where the plaintiff had consented to an 
aortogi'aphy which was perfoiTned. As a 
result of this, he was paralyzed from the 
waist down. In passing on an instruction 
to the jury charging them that a physician 
had a duty to disclose “all of the facts 
which mutually affect his rights and in- 


JUNE, 1974— VoL. 126, No. 6 


189 


INFORMED CONSENT— ALSOBROOK 


terests and the surgical risks, hazards, and 
dangers, if any . . the court said, “a 
physician violates his duty to his patients 
and subjects himself to liability if he with- 
holds any facts which are necessary to 
form an intelligent consent by the patient 
to the proposed treatment.” Then the 
court gave the doctor two alternatives: 

One is to explain to the patient every risk at- 
tendant upon any surgical procedure or opera- 
tion, no matter how remote . . ., the other is to 
recognize that each patient represents a separate 
problem, that the patient’s mental and emotional 
condition is important and in certain cases may 
be crucial, and that in discussing an element of 
risk a certain amount of discretion must be em- 
ployed consistent with the full disclosure of facts 
necessary to an informed consent. 

This famous passage set out the basic 
duty of the doctor to fully inform the pa- 
tient before a true consent to therapy 
could be obtained. In order to determine 
what was to be done with his body, the 
patient, with the requisite emotional sta- 
bility, was entitled to all of the informa- 
tion concerning the disposition of his case. 
The doctor now had a duty to inform his 
patient of the risks, consequences, and ben- 
efits of 1) the proposed procedure; 2) any 
alternative procedures; and 3) no treat- 
ment. Only then could true consent to pro- 
cedures be obtained. 

Technical Battery 

Some early cases held that failure to dis- 
close would vitiate a patient’s consent, and 
any treatment which was performed with- 
out consent would be a technical battery. 
Though battery was without intent to 
harm, it was still an unconsented to touch- 
ing of the body, and thus was a technical 
battery. 

In Bang v. Charles T. Miller Hospital,^ 
the plaintiff consented to a cystoscopic ex- 
amination and a transurethral prostatic 
resection. When he obtained his patient’s 
consent, the doctor did not tell him that 
his spermatic cords would be severed. The 
Minnesota Supreme Court followed its rea- 
soning in Mohr and held that if the jury, 
on remand, found that Mr. Bang had not 
consented to his own sterilization, the doc- 


tor was guilty of a battery. Even though 
the patient might run the risk of infection 
if the cords were not severed, the court de- 
cided that the patient, not the doctor, must 
make the decision. 

The same conclusion was reached in 
Berkey v. Anderson.^ The plaintiff con- 
sented to a myelogram as part of the treat- 
ment for a neck injury. When he entered 
the hospital, he had no trouble whatsoever 
with his lower back and legs. However, 
after the procedure, he discovered that he 
had what was called a “rubber leg”. That 
is, when he put weight on the leg, it 
buckled. He had never experienced this 
difficulty before. The plaintiff claims that 
the defendant had never given him any in- 
formation about the consequences of a 
spinal injection, and that he had no knowl- 
edge of what was involved in a myelogram. 
He testified that he would have never per- 
mitted the puncture of his spine had he 
known of the possible results. At the close 
of the plaintiff’s case, the trial court 
granted defendants’ motions for non-suit, 
but the appellate court reversed. In dis- 
cussing the plaintiff’s recovery on a the- 
ory of informed consent, the court held 
that it was the duty of the doctor to prop- 
erly explain any procedure which he per- 
formed. This explanation was necessary 
since the only consent which would effec- 
tively grant permission to operate would 
be an informed consent. If an informed 
consent was not given, the myelogram 
would be termed a technical battery, and 
the defendant would be liable for all dam- 
ages, whether foreseeable or not, which 
might arise. 

Informed Consent as Malpractice 

Though a few jurisdictions held that an 
operation performed without the informed 
consent of the patient constitutes a tech- 
nical battery, most courts rejected this 
theory. They granted recovery in informed 
consent cases on a theory of negligence. 
The basic problem with the negligence the- 
ory is that negligence has two separate ele- 
ments: Duty and a breach of that duty. 
Non-disclosure could easily be seen as a 


190 


J. Louisiana State M. Soc. 


INFORMED CONSENT— ALSOBROOK 


breach, but the courts had trouble deter- 
mining exactly what the duty was. Since 
the jurisdictions which adopted this negli- 
gence theory also thought that an action 
based on informed consent was a question 
of medical malpractice, they adopted the 
community standard of practice. 

In 1960 the Kansas Supreme Court de- 
cided their first case on informed consent, 
Natanson v. Kline.^ The plaintiff was suf- 
fering from breast cancer and underwent 
a radical mastectomy. After the operation, 
she engaged the defendant for cobalt 
treatments, and in the course of radiation 
therapy, she sustained injuries allegedly 
due to excessive doses of radiation. The 
jury found that the defendant was not 
guilty of any negligence in administering 
the cobalt radiation, and the plaintiff ap- 
pealed. She had requested an instruction 
about informed consent, but the trial judge 
denied it. Thus, the court had the issue of 
informed consent squarely before them, 
and they took a long, hard look at the vari- 
ous theories. After rejecting the battery 
approach taken in Bang, the court, relying 
on the rationale of Salgo, concluded that 
the action was based on a negligence the- 
ory. Though they properly recognized the 
suit as one in malpractice, they had a dif- 
ficult time determining what the standard 
would be, and they finally decided that the 
medical community could set its own stan- 
dard. 

The primary basis of liability in a medical 
malpractice action is the deviation from the stan- 
dard of conduct of a reasonable and prudent 
medical doctor of the same school of practice as 
the defendant under similar circumstances. 

The court remanded the case in order 
that the jury be allowed to pass on the 
question of informed consent using the 
standards established by it. 

Using the same reasoning as the Kansas 
court, Texas adopted the rule that a pa- 
tient has a right to be informed of all of 
the risks incident to medical treatment if 
a reasonable medical practitioner of the 
same school or community would have dis- 
closed them, Wilson v. Scott J The plaintiff 
consented to a stapedectomy. As a result 


of the operation, he lost all hearing in his 
left ear. He also suffered from vertigo, 
instability, and tinnitus. He alleged that 
he had never been warned about these con- 
sequences. The court felt that no recovery 
could be based upon a lack of information 
about the possibilities of vertigo, instabil- 
ity, or tinnitus since no standard for dis- 
closure of these ailments had been proven. 
However, they felt that recovery could be 
granted for loss of hearing, since the de- 
fendant doctor set the general standard by 
his own testimony when he testified that 
he told the plaintiff about the chance for 
loss of hearing. Since there was conflict- 
ing testimony as to whether the plaintiff 
had been warned about a possible hearing 
loss, and since the jury had not been asked 
to pass on the question of informed con- 
sent based on the standard practice of the 
community, the court remanded the case.® 

One year after Natanson, the Delaware 
Supreme Court decided DiFilippo v. Pres- 
ton.^ The plaintiff complained of a lump 
in her throat which was diagnosed as an 
enlargement of the thyroid gland. The de- 
fendant doctor performed a thyroidecto- 
my, but he did not warn Mrs. DiFilippo of 
possible damage to her recurrent laryngeal 
nerves. She consented to the operation, 
and these nerves were damaged. In the 
lower court the question of negligence in 
treatment was resolved in the defendant’s 
favor. On appeal, the plaintiff urged the 
doctrine of informed consent as a major 
basis for recovery. The court affirmed the 
lower court and decided that the doctor 
had no duty to warn his patient about pos- 
sible damage. The evidence showed that 
it was not the practice of the Bloomington 
doctors to warn their patients of possible 
injury to recurrent laryngeal nerves. 
Since the community standard was met, no 
negligence was proved. 

In Govin v. Hunter, the court affirmed 
a summary judgment in favor of the de- 
fendants. Plaintiff consented to a strip- 
ping of a varicose vein in her leg. She 
testified that the defendant told her that 
he could strip the vein with only one in- 


JUNE, 1974— VoL. 126, No. 6 


191 


INFORMED CONSENT— ALSOBROOK 


cision behind the ankle and one behind the 
knee. In fact, six incisions were necessary, 
and these resulted in scars on her legs. At 
trial, she offered no medical evidence that 
the doctor must warn the patient of this 
possibility, and the court agreed that the 
omission was fatal. Since the standard of 
medical care had not been shown, the jury 
could not have found any breach of a phy- 
sician’s duty. 

As a result of requiring that the plain- 
tiff present expert medical testimony to 
establish a standard of disclosure, the 
courts had effectively changed the nature 
of informed consent. The original basis de- 
termined in Salgo, was that a plaintiff 
could not validly consent to an operation 
unless all of the information concerning 
the risks of the procedure were explained 
to him. Interestingly, the court did not 
mention any need to establish a medical 
standard, since his right to determine the 
disposition of his own body determined 
the necessity for an informed consent. 
However, where the plaintiff is required 
to establish that the medical community 
would inform a patient of a risk inherent 
in a procedure this right is diminished, for 
the plaintiff must establish the right as a 
necessary part of his case. 

The Privilege of Non-Disclosure 

As the duty to disclose was being ac- 
cepted by various courts, other refine- 
ments were being given to the basic in- 
formed consent theory. In Crouch v. 
Most,^~ the plaintiff was bitten by a rattle- 
snake. The defendant administered “anti- 
venin” as an antidote. A few days later 
dry gangrene developed, and the hand was 
amputated. The plaintiff contended that 
the doctor failed to give a warning about 
possible gangrene before he administered 
the drug. In summarily rejecting this ar- 
gument, the court said that the doctrine 
of informed consent could not apply to 
emergency conditions. Since the plaintiff 
was in no condition to determine any 
course of treatment and could in no way 
give consent, it would be useless for the 
doctor to fully discuss the possibilities of 


treatment in order to get informed con- 
sent. 

Another limitation on the theory was 
presented in Block v. McVay.^^ The plain- 
tiff underwent surgery for a lymph node 
tumor. When the defendant surgeon re- 
moved the lump, he discovered that it was 
attached to a bundle of nerves, and only 
then did he realize that the tumor was not 
one of the lymphatic system, but a benign 
nerve tumor. As a result of the operation, 
the plaintiff experienced numbness in her 
right arm, and it was difficult for her to 
grasp any object in her right hand. After 
deciding that the doctor was not negligent 
in making the mistaken diagnosis, the 
court discussed the doctor’s failure to ad- 
vise the plaintiff about this possible result. 
They felt that since the doctor did not 
know that the tumor was attached to the 
nerve until after its resection, and since 
at the time of the operation, the doctor 
was under the impression that the surgery 
would be a removal of a lymph node tu- 
mor, he was not under a duty to disclose 
any ill effects of a nerve tumor resection. “ 

It has also been held that the physician 
is not under a duty to disclose all risks of 
a certain procedure if the risks not dis- 
closed were only remote possibilities.^® 

One recent case has held that a physi- 
cian is only under a duty to disclose only 
those risks which are reasonably foresee- 
able, Mason v. Ellsivorth.^^ The plaintiff’s 
esophagus was perforated during an esoph- 
agoscopy. Evidence was introduced to 
show that the risk of such a complication 
was only 14 to % of 1 percent. The court 
held as a matter of law that under these 
conditions, there was no foreseeable risk. 

The widest privilege concerning disclo- 
sure is the therapeutic one, which was 
originally recognized in Salgo, supra. Ac- 
cording to that court, the second course 
of action which a physician might follow 
was that of discretionary disclosure where 
the patient’s mental and emotional condi- 
tion warranted special treatment. This doc- 
trine was accepted in Roberts v. Wood,^~ 
where the court felt that apprehension and 


192 


J. Louisiana State M. Soc. 


INFORMED CONSENT— ALSOBROOK 


fear caused by full disclosure of all risks 
inherent in a certain procedure might have 
a detrimental effect on a patient. In Wat- 
son V. Clutts,^^ the plaintiff experienced 
bilateral paralysis of the vocal cords fol- 
lowing a removal of her thyroid gland. 
She claimed that her doctor did not warn 
her of the possible complication. The court 
held that a doctor has two duties. The pri- 
mary one is to do what is best for his pa- 
tient. The second duty is one of disclosure. 
If the two duties conflicted, the primary 
one would prevail. Thus, where the dis- 
closure might unduly frighten the patient 
before an operation, certain risks need not 
be revealed.^® 

The problem of therapeutic privilege 
also was discussed in Nishi v. HartwelL^^ 
The plaintiff was paralyzed from the waist 
down after undergoing thoracic aortog- 
raphy. The paralysis was a known side 
effect of the contrast medium Urokon. 
The plaintiff contended that the failure of 
the doctor to warn vitiated his consent. 
One defendant testified that the plaintiff 
was not informed of the risks since such 
information might have the effect of in- 
creasing the blood pressure of a man suf- 
fering from hypertension, and therefore, 
it was not in his patient’s best interest. He 
testified: 

I mentioned he had high blood pressure, he had 
pain in his chest which we were trying to find 
an answer to, and if I would have sat down with 
Dr. Nishi and said, “We are about to inject some- 
thing into you which has a remote chance of 
causing you to be paralyzed, you may get an im- 
mediate reaction which may cost you your life.” 
If I had said these things to Dr. Nishi, I think 
it would have been a terrible mistake. 

The court felt that since the doctor had 
shown that it was in the plaintiff’s best 
interest not to be informed of the con- 
tingency, the defendant was covered by 
the therapeutic exception to the duty to 
disclose. 

It might be argued that the discussed 
exceptions to the duty to disclose are also 
a derivation of the plaintiff’s right to de- 
termine how he will dispose of his body, 
and, in the last analysis, they might be. 


However, the law and medical science both 
recognize that each patient differs from 
every other one in his physical and emo- 
tional makeup. A disclosure that may be 
beneficial to one patient might be detri- 
mental to another, and the law should al- 
low for this eventuality. However, these 
exceptions should be properly relegated to 
matters of defense, since it would be the 
doctor’s burden to convince the fact finder 
that he had a valid reason for not disclos- 
ing certain risks. 

Revival of the Right 

Consistent with the essence of Salgo, 
supra, the most recent opinions speak of 
the doctrine of informed consent in terms 
of the patient’s right to know the risks in- 
herent in a specific procedure. Under this 
interpretation, the patient’s substantive 
right is not based on any duty imposed 
upon the doctor by the medical community. 
The courts see the right as a natural cor- 
ollary to the proposition that all normal 
adults have the right to determine the dis- 
position of their own bodies. 

In Hunter v. Brown/^ the defendant per- 
formed an unsuccessful dermabrasion pro- 
cedure. Instead of reducing the excess pig- 
mentation on the plaintiff’s face, the op- 
eration caused an increase. Evidence was 
offered to show that in this procedure, 
there is a risk of resulting hyperpigmenta- 
tion, especially when the patient is (as was 
the plaintiff) an Oriental. The court de- 
cided that when these facts were coupled 
with proof of non-disclosure, the plaintiff 
had established her case. The court ana- 
lyzed the problem in terms of an absolute 
right to information because of the doctor- 
patient relationship and the right of a pa- 
tient to determine what is to be done to 
his body. 

Four recent cases have adopted this line 
of thought. The first was Canterbury v. 
Spencer^ The plaintiff was paralyzed fol- 
lowing a laminectomy. Since at the time 
the operation was performed, he was a 
minor, his mother consented to the pro- 
cedure after being informed that it was 
no more dangerous than any other opera- 


JUNE, 1974— VoL. 126, No. 6 


193 


INFORMED CONSENT— ALSOBROOK 


tion. Among other things, the plaintiff 
alleged that the doctor was negligent in 
not advising the mother of the possible 
risk of paralysis. At the close of this case, 
the lower court directed verdicts in favor 
of the defendants without alluding to the 
doctor’s duty of disclosure. 

In granting reversal, the Court of Ap- 
peal held that the context in which the 
duty of risk/disclosure arises, is the pre- 
rogative of the patient, not the physician, 
and the physician could not determine for 
himself the direction in which his interests 
seem to lie. The court rejected the idea 
that medical standard in the community 
was the basis of the duty. They recognize 
that, “the physician’s non-compliance with 
a professional custom to reveal, like any 
other departure from prevailing medical 
practice, may give rise to liability to the 
patient.” However, they held that the pa- 
tient’s cause of action is not dependent 
upon the existence and non-performance 
of a relative professional tradition. In 
order to give true substance to the pa- 
tient’s right of self-determination, they 
felt that the law must set the standard, for 
if the law does not, the medical community 
might not. They declared: 

Society demands that everyone under a duty 
to use care observe minimally a general standard. 
Familiarly expressed judicially, the yardstick is 
that degree of care which a reasonably prudent 
person would have exercised under the same or 
similar circumstances. Beyond this, the law re- 
quires those engaged in activities requiring unique 
knowledge and ability to give a performance com- 
mensurate with the undertaking. 

The essence of the Canterbury decision 
was to hold that, “the patient’s right of 
self-decision shapes the boundaries of the 
duty to reveal.” The test for determining 
what risks must be divulged is the relation- 
ship of the risk to the patient’s decision. 
The court held: 

All risks potentially affecting the decision 
must be unmasked. And to safeguard the pa- 
tient’s interest in achieving his own determina- 
tion on treatment, the law must itself set the 
standard for adequate disclosure. 

The court then discussed how they 
thought the physician should handle this 


responsibility; however, it is apparent 
that the duty imposed upon the physician 
boils down to whether or not the physician 
reasonably divulged enough risk for the 
patient’s informational needs. The court 
attempted to say that this was an objec- 
tive rather than a subjective standard, but 
placed the final determination in the “fact 
finder” to deteimiine if the physician’s 
communication was unreasonably inade- 
quate so as to make him liable to the 
patient. 

While the court in Canterhu't'y specifi- 
cally recognized the emergency and thera- 
peutic approach exemptions, it held with 
regard to the latter that this exemption, 
“does not accept the paternalistic notion 
that the physician may remain silent sim- 
ply because divulgence might prompt the 
patient to forego therapy the physician 
feels the patient really needs.” Further- 
more, lay-witness testimony can compe- 
tently establish a physician’s failure to dis- 
close particular risk information and ex- 
perts are unnecessary to show the ma- 
teriality of a risk to a patient’s decision on 
treatment. In summary, the court held 
that the standard measuring performance 
of the duty by the physician to inform the 
patient is “a rule of reason”. 

The second case which recognized this 
theory arose in California. Cobbs v. 
Grant.-^ The plaintiff underwent surgery 
for a duodenal ulcer. Nine days after the 
operation he went home, but due to intense 
pain in his abdomen, he returned to the 
hospital. Once there, it was found that an 
artery had been severed in his spleen, 
necessitating its removal. A month and a 
half after the spleen’s removal, plaintiff 
was found to have developed a gastric 
ulcer, and the doctors performed a third 
operation, this time removing 50 percent 
of the plaintiff’s stomach. Both the possi- 
bility of injury to the spleen and the devel- 
opment of a gastric ulcer are risks inher- 
ent in the surgical treatment of a duodenal 
ulcer. To further complicate matters, the 
plaintiff returned to the hospital after 
discharge from his third operation due to 


194 


J. Louisiana State M. Soc. 


INFORMED CONSENT— ALSOBROOK 


internal bleeding. This bleeding was 
caused by a premature suture absorption, 
which is a risk inherent in any operation. 
At trial, the jury returned a general ver- 
dict for the plaintiff, and the defendant 
appealed. The court held that the question 
of negligence should not have gone to the 
jury, since the surgery had been per- 
formed adequately, but the question of in- 
formed consent could be in dispute. The 
case was remanded since the court could 
not determine from the general verdict 
upon which theory recovery was based. 

The significance of the case lies in the 
court’s discussion on informed consent. 
First, the court held that cases dealing 
with informed consent should be sounded 
in negligence. Secondly, the court discard- 
ed the medical community standards’ ap- 
proach. In doing so, the court employed 
the postulate that: 

Patients are generally persons unlearned in 
the medical sciences and therefore, except in rare 
cases, the courts may safely assume the knowl- 
edge of the patient and physician are not in 
parity; . . . that a person of adult years and in 
sound mind has the right, in the exercise of con- 
trol over his own body, to determine whether or 
not to submit to lawful medical treatment; . . . 
that the patient’s consent to treatment, to be ef- 
fective, must be an informed consent; . . . that 
the patient, being unlearned in medical sciences, 
has an abject dependence upon and trust in his 
physician for the information upon which he 
relies during the decisional process, thus raising 
an obligation in the physician that transcends 
arms-length transactions. 

Therefore, for a meaningful decision by 
the patient, the physician must divulge all 
information relevant to the treatment or 
procedure. The patient, not the physician, 
is the one to determine the direction in 
which he believes his interests lie and to 
enable him to chart that course, familiar- 
ity with therapeutic alternatives and their 
hazards is essential. The court, drawing 
on Canterbury, reiterated that the pa- 
tient’s right of self-decision is the measure 
of the physician’s duty to reveal. The court 
further held that the burden of proving 
non-disclosure rests on the plaintiff, but 
once such evidence has been produced. 


then the burden shifts to the physician to 
justify the failure to disclose. 

Wilkinson v. Vesey^^ is the third case in 
which the court established the right to 
know doctrine. A shadow on an x-ray was 
diagnosed as a malignant tumor in the 
plaintiff’s upper mediastinum, and radia- 
tion therapy was commenced. As a result 
of the radiation, her skin broke down, and 
she was required to seek repair through 
plastic surgery. This procedure did not 
completely solve her problems. By the time 
of trial, she had eight operations which 
included: Skin grafts, removal of seven 
ribs, her clavicle and sternum, and move- 
ment of her heart with cushioning pro- 
vided by muscle taken from her left arm. 
At no time was she informed of the possi- 
bility that the radiation therapy might 
have this adverse effect. She offered three 
grounds for recovery, including a theory 
of informed consent. At the close of the 
trial, the judge granted directed verdicts 
in the defendant’s favor, but the Supreme 
Court reversed. With regard to informed 
consent, the court held that it was the pa- 
tient’s right to make his decision on his 
own individual value judgment the very 
essence of his freedom of choice, and thus 
it should not be left to the medical profes- 
sion to determine what the patient should 
be told. Furthermore: 

There is no necessity for expert testimony since 
the jury could determine, without recourse to a 
showing by the plaintiff of what the medical fra- 
ternity in the community tells its patients, the 
reasonableness or unreasonableness of the extent 
of a physician’s communication with a patient. 

While the Rhode Island Supreme Court, 
in Wilkinson, agreed with Canterbury, 
their reasoning was somewhat different. 
They held that the patient had an undis- 
puted right to receive information which 
would enable him to make a choice and 
that the decision as to what is or is not 
material is a human judgment which could 
be made by the jury alone. They recog- 
nized, however, that this would not pre- 
vent the physician from introducing evi- 
dence of the standard of medical practice 
to substantiate his lack of disclosure. By 


June, 1974— Vol. 126, No. 6 


195 



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196 


J. Louisiana State M. Soc. 


INFORMED CONSENT— ALSOBROOK 


the same token, the plaintiff may have to 
present an expert witness to establish the 
known risk involved in the procedure in 
controversy. The court further observed 
that there was no need for the physician 
to disclose risks that are likely to be known 
by the average patient or may be known 
because of the patient’s past experience. 

The most recent decision comes from the 
appellate division of New York. In Fogal 
V. The Genesee Hospital , the court adopt- 
ed the holding in Canterbury and granted 
a new trial on the issue of informed con- 
sent against the surgeon and anesthesiolo- 
gist. The case involved injury to the plain- 
tiff’s wife as a result of the use of a hypo- 
thermia blanket to cool her body tempera- 
ture during surgery. Mrs. Fogal was ad- 
mitted to the hospital and underwent sur- 
gery for an abdominal aortic aneurysm. 
Because the surgery involved stopping the 
blood supply to portions of the body for 
extended periods of time, hypothermia was 
used to cool and slow the body’s metabo- 
lism during the operation. The vascular 
surgeon ordered the hypothermia, which 
was administered by the anesthesiologist. 

As a preface to adopting Canterbury , 
the court reiterated that New York law re- 
quired a physician to obtain the informed 
consent of his patient to a surgical pro- 
cedure and that the basis of any action for 
such failure would be under the theory of 
assault and battery. As in the preceding 
cases, the court acknowledged that some 
jurisdictions have held that the duty to 
disclose must be established by expert 
medical testimony of the standards of the 
medical profession. However, the court 
found the rule in Canterbury to be pref- 
erable and held that a doctor is obliged to 
divulge to his patient: 

The risks which singly or in combination, test- 
ed by general considerations of reasonable dis- 
closure under all the circumstances, will ma- 
terially affect the patient’s decision whether to 
proceed with the treatment. This is not a retro- 
spective determination. There should be no criti- 
cism of the physician unless the fact-finder de- 
termines that the information supplied was un- 
reasonably inadequate. 

The New York court further recognized 


that it was no answer that the patient did 
not state she would have refused the op- 
eration had she known of this particular 
hazard because her statement would not 
be conclusive evidence. Further, whether 
the damage is causally related to the fail- 
ure to disclose must be determined objec- 
tively. For, it matters not what the pa- 
tient has decided, but what would a rea- 
sonable person in the patient’s circum- 
stances, having sufficient knowledge of 
the material risk incident to the proce- 
dure, have decided. The New York court 
concluded by holding that the fact that the 
hypothermia was appropriate or necessary 
was beside the point, since the patient had 
the right to choose between two apparent 
dangers, “one attendant upon surgery, and 
the other resulting from the continuation 
of the existing condition because of a de- 
cision not to undergo surgery”. 

These latest decisions emphasize that 
the real basis for the dispute over the na- 
ture of a person’s right to information is 
a procedural one. If the doctor need only 
disclose that information which would be 
disclosed by a competent physician in the 
community, the plaintiff carries the bur- 
den of proof and must establish that com- 
munity standard. If for some reason he 
cannot establish the standard, he cannot 
recover. In addition, those jurisdictions 
which adopted this rule, also require that 
expert testimony be put in evidence to 
establish the standard.-® Since the amount 
of disclosure is seen as a medical question, 
expert testimony is the only basis by which 
a jury can determine, without resorting to 
conjecture, whether a physician has skill- 
fully performed his duties. The question is 
not what would a reasonable man do; it is 
what would a reasonable doctor do.-^ If on 
the other hand, the right to disclosure is 
imposed by law, the plaintiff’s burden is 
completely different. Since the law im- 
poses the duty, no standard need be shown, 
and since no standard need be shown, no 
expert testimony is necessary.-® Then the 
question is one of human judgment: as 
seen from the position of the plaintiff, has 


June, 1974 — Vol. 126, No. 6 


197 


INFORMED CONSENT— ALSOBROOK 


he received enough information to make 
an intelligent choice. Since the plaintiff 
is not an expert himself, and he made his 
choice without the benefit of expert testi- 
mony, (his own doctor’s disclosure of the 
risk) there seems no real reason why a 
juror, who must decide whether a reason- 
able patient in the plaintiff’s shoes re- 
ceived enough information to make an in- 
telligent consent, must have medical testi- 
mony to make his decision. 

Even though expert testimony is not 
necessary to establish the standard, it does 
have a major role in deciding the ultimate 
issue. The courts recognize that the 
amount of information given depends on 
the condition, both physical and mental of 
the plaintiff, so the major privileges were 
incorporated into the right to know the- 
ory,29 By this method the defendant has 
the opportunity to show why certain risks 
were not explained, and 1) therapeutic 
considerations, 2) unforeseeable risks, 3) 
emergency, 4) minor risks, or 5) general 
knowledge of an inherent risk all become 
defenses to this negligent action.®” 

In a given case, evidence of a medical standard 
might well persuade the trier of fact that the 
surgeon disclosed all of the facts which the plain- 
tiff should know for the purpose of informed con- 
sent. But such proof should be the physician’s 
burden and should be weighed as any other evi- 
dence and be judged by “reasonable man” stan- 
dards of conduct.^* 

In short, the three latest cases involving 
the doctrine of informed consent are all in 
agreement, and their holdings fully reflect 
and protect a patient’s right to determine 
whether or not he will embark on a spe- 
cific course of treatment. Since the rights 
of a person are reflected in the procedure 
followed in a court, the plaintiff’s only 
burden is that he establish that he was not 
apprised of a risk. Once this prima facie 
case is shown, the doctor has the oppor- 
tunity to explain why he did not inform 
the patient, and he may introduce medical 
testimony in order to substantiate his ulti- 
mate decision. Finally, it is the fact find- 
er’s duty to decide what was reasonable 
under the situation. 


The Question of Causation 

Since recovery for lack of informed con- 
sent is predicated on negligence, it is nec- 
essary that a causal relationship be shown 
between the lack of information and the 
damage. If the patient with the knowledge 
of all of the risks, would have given his 
consent to an operation, it appears unjust 
to allow him recovery on what would be- 
come a technicality. A man with a back- 
ache might not consent to a procedure that 
has a 20 percent risk of paralysis, but a 
man who is bedridden because of back 
pain, probably would. Thus, it is the plain- 
tiff’s burden to show that a reasonable 
person would not have consented to the 
procedure if he would have known the 
risk. 

In Shelter v. Rochelle , the plaintiff 
signed a written consent authorizing re- 
moval of a cataract. The lens was removed 
according to standard medical procedure, 
but over a period of time, the plaintiff de- 
veloped glaucoma. Her sight in that eye 
deteriorated to 20/200. The jury returned 
a verdict for plaintiff after being instruct- 
ed on informed consent. The defendant 
moved for a judgment N.O.V., on the basis 
that the court failed to instruct the jury 
that the defendant would only be liable if 
his failure to disclose was the proximate 
cause for the sight loss. The court denied 
the motion, so appeal was taken. The ap- 
pellate court reversed. The court held that 
proximate cause was an essential element 
before recovery. The test for causation 
was not a “but for” rule, but one where 
the plaintiff must show that she would not 
have had the operation if disclosure had 
been made. Since no proof was offered in 
this regard, the judgment was reversed.®® 

The courts in Canterbury, Cobbs, Wilk- 
inson and Fogal all recognized the neces- 
sity for the causal relation. However, they 
decided that the test proposed in Shelter, 
supra, was not adequate, since a fact 
finder would have to base its conclusion 
on a plaintiff’s self-serving testimony. His 
statement of whether or not he would have 
consented is speculation based on an after- 


198 


J. Louisiana State M. Soc. 


INFORMED CONSENT— ALSOBROOK 


the-fact analysis. In addition, the plain- 
tiff would be asked to make a decision 
knowing that the undisclosed complication 
actually materialized. In summary, his 
statement could have little credibility. 

In place of the subjective test, the court 
adopted an objective standard. The basis 
for causation became: would a prudent 
person informed of all of the material risks 
have consented to the operation. The pa- 
tient’s testimony could still offer some 
insight, and since it would be considered 
in light of the reasonable standard, the 
fact finder would have a better opportu- 
nity to find the true answer. 

The question of causation is the thorn- 
iest of all in a suit where the plaintiff is 
seeking recovery based on a theory of in- 
formed consent. At the same time, the 
jury must ultimately decide the matter, 
and the reasonable man standard set forth 
in Canterbury, Cobbs and Wilkinson, 
states the best patient test, since the ne- 
cessity of speculation is markedly reduced. 

Conclusion 

In its short life, the theory of informed 
consent has experienced many alterations. 
Its roots reach back to the turn of the cen- 
tury and tap the same source that allowed 
Anna Mohr to change and make legal his- 
tory. The idea that an adult is the master 
of the disposition of his own body has 
become an almost sacred principle. All it 
took were a few words in Salgo v. Leland 
Standf ord, Jr. University Board of Trust- 
ees to put forth the corollary that a person 
who did not know the risks and alterna- 
tives could not be the master. Sometime 
in the 1960s this idea of the patient being 
the master was changed. With Natanson 
V. Kline the courts came to think that the 
master’s right was one given to him by 
the medical community. No longer was 
there a right to knowledge inherent in a 
patient, but he had to show that the de- 
fendant’s fellow doctors felt that more in- 
formation should have been disclosed. 
Since he had to establish the right by prov- 
ing the standard of the community, the 
right became a gift from the doctor. 


The newer cases seem to be reviving the 
master’s right. After a long, hard analysis 
of the problem, some courts have decided 
that a person has a right to full disclosure 
of all of the risks involved in a procedure. 
In addition, he has a right to be informed 
of any alternatives that might be taken 
in order to bring about the ultimate cure. 
Since medical problems are as complex as 
the person being treated, the law does 
recognize that not all information should 
be given to all patients, and for that case 
it gives a doctor a defense. However, it is 
important to note that the right of a pa- 
tient is now the starting point, and it is 
up to the doctor to justify his non-dis- 
closure. 

There is little doubt that we live in a 
legal era of judicial recognition of indi- 
vidual rights, and therefore, it is not sur- 
prising that the courts have superimposed 
the right to know doctrine over informed 
consent. However, this new legal theory 
has imposed another hazard into the prac- 
tice of medicine for the fact finder will be 
the sole determinator of whether the doc- 
tor acted in a reasonable fashion. In the 
end, the intangible aspects of the doctor- 
patient relationship will determine wheth- 
er a professional healer will become the 
next defendant. 

Acknowledgment 

I thank Rob Bjork, one of our law clerks 
and the son-in-law of the late W. Ford 
Reese, for his assistance in the prepara- 
tion of this article. 

References 

1. Mohr V. Williams, 95 Minn. 261, 104 NW 12 

(1905). 

2. Schleoendoff v. Society of New York Hospital, 211 
NY 125, 104 NE 92 (1914). 

3. CalApp2d 560, 317 P2d 170 (1957). 

4. 251 Minn. 427, 88 NW2d 186 (1958). 

5. 1 CalApp3d 790, 82 Cal Rptr 67 (1969). 

6. 186 Kan 393, 350 P2d 1093 (1960). Aff’d. on reh. 
187 Kan 186, 354 P2d 670 (1960). 

7. 412 SW2d 299 (Tex 1967). 

8. Courts have also found that the defendant has 
breached the community standard with respect to dis- 
closure where a pediatrician did not warn the parents of 
a nine-year-old child that the use of strep-combiotic 
might cause deafness, Koury v. Folio, 272 NC 366, 158 
SE2d 548 (1968) ; doctor did not warn his patient of pos- 
sible dermatitis when a gold compound was used in the 
treatment of arthritis, diRossi v. Wein, 24 AD2d 510, 


June, 1974— Vol. 126, No. 6 


199 


INFORMED CONSENT— ALSOBROOK 


261 NYS2d 623 (1965); the doctor did not disclose to 
the parents of an infant that a procedure was unorthodox 
and there were certain risks incident to or possible in its 
use. Fiorentino v. Wenger, 26 AD 693, 272 NYS2d 557 
(1966). One court has held that a plaintiff has a right 
to prove the standard and go to the jury where he 
alleged that he was not advised that he might suffer 
brain damage due to insulin shock therapy, Aiken v. 
Clary, 396 SW2d 668 (Mo, 1965). In a more recent case, 
the plaintiff was not warned about possible paralysis due 
to excessive radiation received during treatment for 
Hodgkin’s disease, Zebarth v. Swedish Hospital Medical 
Center, 81 Wash2d 12, 499 P2d 1 (1972). 

9. 53 Del 539, 172 A2d 333 (1961). 

10. 374 P2d 421 (Wyo 1962). 

11. For other cases where recovery on the basis of 
informed consent was not granted due to failure to 
establish the community standard of care, see, Roberts v. 
Young, 369 Mich 133, 119 NW2d 627 (1963) — failure to 
warn of possible abdominal infection following cesarean 
section birth; Williams v. Menehan, 191j Kan 6th, 379 
P2d 292 (1963) — failure to warn the parents of a three- 
year-old boy of the possibility of death due to the injec- 
tion of 100 mg. of sodium pentothal into a heart catheter; 
Collins V. Itoh, Montana , 503 P2d 36 (1972) — 
failure to warn of a one-half of one percent to three per- 
cent risk of hypoparathyroidism in a thyroidectomy ; 
Ditlow V. Kaplan, 181 So2d 226 (Fla App 1966) — failure 
to warn of risk of esophagus puncture during a gastro- 
scopic procedure. See also Petterson v. Lynch, 59 Misc2d 
469, 299 NYS2d 244 (1969). 

12. 78 N Mex 406, 432 P2d 250 (1967). 


13. 80 S Dak 469, 126 NW2d 808 (1964), 

14. See also Megaard v. Estate of Feda, 152 Mont 47, 
446 P2d 436 (1968) ; Doerr v. Movius, 154 Mont 346, 
463 P2d 477 (1970). 

15. Yates v. Harms, 193 Kan 320, 393 P2d 982, mod. 
on reh. 194 Kan 675, 401 P2d 659 (1965). 

16. 3 Wash Appl 298, 474 P2d 909 (1970). 

17. 206 FSupp 579 (SD Ala 1962). 

18. 262 NC 153, 136 SE2d 617 (1964). 

19. The Alaska Supreme Court reached the same con- 
clusion in Patrick v. Sedwick, 391 P2d 453 (Ala 1964). 

20. 52 Hawaii 188, 473 P2d 116 (1970). See also 

Scarnes v. Taylor, 272 NC 386, 158 SE2d 339 (1968) ; 
Getchell v. Hiestand, 489 P2d 953 (Ore 1971). 

21. 4 Wash Appl 899, 484 P2d 1162 (1971). 

22. 464 F2d 772 (DC Cir 1972). 

23. 8 Cal3d 229, 502 P2d 1, 104 Cal Rptr 505 (1972). 

24 RI , 295 A2d 676 (1972). 

25. 41 AppDiv2d 468, NYS2d (1973). 

26. See cases cited in notes 8 through 11. 

27. Aiken v. Clary, supra note 8 ; DiFilippi v. Pres- 
ton, supra note 9. 

28. Canterbury v. Spence, supra; Cobbs v. Grant, 
supra ; Wilkinson v. Vesey, supra ; Fogal v. Genesee, 
supra. 

29. Wilkinson v. Vesey, supra. 

30. See selection on privileges. 

31. Hunter v. Brown, 4 Wash App 899, 484 P2d 1162, 
1167 (1971). 

32. 2 Ariz Appl 358, 409 P2d 74 (1965). 

33. This same causation test was used in Natanson v. 
Kline, reh. 187 Kan 186, 354 P2d 670 (1960). 


HiBeRDia 

nanonaL 


200 


J. Louisiana State M. Soc. 



Scimitar Syndrome Associated with Central 
Nervous System Anomalies 

• A 2-month-old infant with respiratory distress since birth demon- 
strated x-ray evidence of the scimitar syndrome. Aortography dem- 
onstrated aortic origin of the blood supply to a segment of the 
right lower lobe. At autopsy, malformations of the gyri of the 
cerebral cortex were also identified. The question of pleomorphism 
of the scimitar syndrome with multiple organ system involvement 
is raised. 


T HE scimitar syndrome, first described 
by Cooper^ in 1836 and Park- in 1912, 
is a complex malformation of the heart, 
lungs and blood vessels. Also described is 
the frequent association of hemivertebrae 
and rib anomalies. 

The scimitar syndrome receives its name 
from the scimitar-like roentgenographic 
appearance^ of the anomalous vein con- 
necting most or all of the right pulmonary 
veins with the inferior vena cava. This 
venous malformation^ is frequently asso- 
ciated with: 1) hypoplasia of the right 

lung with bronchial anomalies; 2) dex- 
troposition or dextrorotation of the heart; 
3) hypoplasia of the right pulmonary ar- 
tery; and 4) anomalous subdiaphragmatic 
systemic arterial supply to the lower lobe 
of the right lung directly from the aorta 
or its main branches and other intracar- 
diac abnormalities. 

The purpose of this paper is to present 
a case of scimitar syndrome with the ad- 
ditional heretofore undescribed associated 


From the Department of Pediatrics, Louisiana 
State University School of Medicine and Depart- 
ment of Radiology, Tulane University School of 
Medicine, New Orleans. 

Work was supported by the Mental Health Ad- 
ministration, Childrens Bureau Project 254 and 
USPHS Grant HE 0530411. 

Reprint requests to Dr. Shadravan; his present 
address is: Department of Pediatrics, Earl K. 
Long Memorial Hospital, Baton Rouge, Louisiana 
70805. 


IRAJ SHADRAVAN, MD 
RICHARD L. FOWLER, MD 
FRANCIS A. PUYAU, MD 
New Orleans 

findings of congenital cerebral cortical 
anomalies and a dermoid cyst. 

Case Report 

J.B. was a full term white male born to a 27- 
year-old primigravida by breech delivery. Apgar 
score was 2 at 1 minute and 8 at 10 minutes. 
There was no history of prenatal complications. 
Persistent tachypnea and cyanosis were noted de- 
spite administration of oxygen and antibiotics. 
He was transferred to our hospital for evaluation 
at the age of 2 months. The infant, on physical 
examination, was small and cyanotic. A small 
mass was noted on the right brow. Heart sounds 
were best heard to the right of the midline. 
Breath sounds were equal bilaterally. EKG 
showed right axis deviation and probable right 
ventricular hypertrophy. The diagnosis of scim- 
itar syndrome was made by the characteristic 
configuration on the chest x-ray (Fig lA and 
diagram IB). 

Displacement of the cardiac shadow into the 
right hemithorax was thought to be due to atel- 
ectasis or hypoplasia of the right lung. A right 
paracardiac opacity was suggestive of an abnor- 
mal vessel. The vasculature in the left lung ap- 
peared prominent. Hemivertebrae were noted 
from T9-11, and multiple rib anomalies were 
present. 

The diagnosis was confirmed by abdominal 
aortography which revealed an abnormal vascular 
supply to the right lung from the abdominal aorta 
(Fig 2A). The catheter passed via the inferior 
vena cava into the right atrium, right ventricle, 
pulmonary artery and, through a patent ductus 
arteriosus, into the descending aorta. At 1.5 sec- 
onds after injection of the contrast material, a 
single venous channel draining into the inferior 
vena cava at its junction with the right atrium 
was visualized (Fig 2B). 


June, 1974— Vol. 126, No. 6 


201 


SCIMITAR SYNDROME— SHADRA VAN, ET AL 



Fig lA. The chest film shows displacement 
of the cardiac shadow into the right hemithorax. 
The abnormal vessel (arrow) is visualized as a 
right paracardiac density (scimitar sign). 


Fig IB. Diagram of film in Fig lA indicating 
anomalous pulmonary vein. 

The child developed seizures following the in- 
jections. His condition deteriorated steadily de- 
spite supportive and anticonvulsive therapy, and 
he died 24 hours following the procedure. 

At postmortem examination, the right supra- 
orbital mass was found to be a dermoid cyst. The 
right lung was very small with sequestration, 
atelectasis, and no obvious aeration. The peri- 
cardial sac was adherent to the right pleural sur- 
face laterally, and the heart was shifted primarily 
into the right hemithorax. 

A vein descended from the hilus of the right 
lung to enter the inferior vena cava (scimitar 
sign. Fig lA). Entering the inferior surface of 


the right lung were three arterial branches which 
originated from the aorta near the level of the 
renal arteries (Fig 2A). One smaller artery orig- 
inating near the celiac axis also supplied this 
lung. 



Fig 2 A. Selective aortogram at 0.5 second 
demonstrates the abnormal vascular supply (ar- 
row) to the right lung from the abdominal aorta. 



Fig 2B. At 1.5 seconds after injection, con- 
trast collects in a venous channel draining into 
the inferior vena cava (arrow). 




202 


J. Louisiana State M. Soc. 





SCIMITAR SYNDROME — SHADRAVAN, ET AL 


There was right ventricular hypertrophy with 
intact atrial and ventricular septa. The aorta 
and pulmonary artery communicated via a patent 
ductus arteriosus. Of note was the finding of 
gross malformations of the cerebral cortex. The 
frontal gyri ran vertically instead of horizontally 
and the rolandic sulcus connected directly with 
the sylvian fissure. 

Discussion 

Cerebral abnormalities have not been 
described with the scimitar syndrome pre- 
viously, and their significance is not clear. 
The consideration should be entertained, 
however, that the syndrome represents a 
generalized process affecting the fetus, 
in which manifestations may vary from 
pure cardiovascular anomalies to a sjm- 


drome of cardiovascular, skeletal and CNS 
anomalies. 

Acknowledgement 

We thank Dr. Judith Fishbein for her 
help in the completion of this report. 

References 

1. Cooper G: Case of malformation of the thoracic 
viscera consisting of imperfect development of right lung, 
and transposition of the heart. London M Gaz 18:600, 
1836 

2. Park EA : Defective development of the right lung 
due to anomalous development of the pulmonary artery 
and vein accompanied by dislocation of the heart simu- 
lating dextrocardia. Proc New York Path Soc 12 (N S) : 
88, 1912 

3. Halasz NA, Halloran KH, Liehow AA: Bronchial 
and arterial anomalies with drainage of the right lung 
into the inferior vena cava. Circulation 14:826-846, 1956 

4. Kiely B, Filler J, Stone S, et aJ: Syndrome of 
anomalous venous drainage of the right lung to the in- 
ferior vena cava. Amer J Cardiol 20:102-116, 1967 


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Please send me background material on prob- 
lem flrinkers that: tells me what community 
organizations can do to help; gives me data on 
various alcohol levels in the blood; describes 
the latest developments in breath-testing 
methods. 

For my patients, please send me information 
to supplement my counsel. 


Problem drinkers can be deadly when 
they get behind the wheel. In fact, 
they are involved in almost 20,000 high- 
way fatalities a year. And the number 
is growing. The only way to reverse this 
trend is to separate the driver from 
his drinking problem. Before he kills 
himself or anyone else. Because punitive 
measures alone have failed to slow this 
needless slaughter, we have to look else- 
where for help. Your office, for instance. 

Where you can counsel him against 
excessive drinking ancf driving. Or where 
you can refer him. Your knowledge and 
experience make you the community’s 
firstlineofdefenseagainstthisepidemic. 

U.S. DEPARTMENT OF TRANSPORTATION NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION. 


Name- 
street- 
City 


-M.D. 


-State. 


-Zip- 


Drunk Driver 
Dept. M.D. 
BOX 1969 
Washington, D.C. 20013 




June, 1974 — Vol. 126, No. 6 


203 




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Postfracture Fat Embolism: A Program of Treatment 
Including Three Case Reports and Review of the 
Pertinent Literature 


• The case reports of three patients who had postfracture fat 
embolism are presented. Such patients are evaluated by monitoring 
of vital signs, serial hemoglobin, hematocrit, and arterial blood gas 
determinations and daily examination of the urine for fat. They are 
considered to have an increased risk of thromboembolic complica- 
tions and are therefore given low molecular weight dextran (500 ml 
daily intravenously). When indicated, we administered a large single 
dose of methylprednisolone (30 mg/kg), and high partial pressure oxy- 
gen as required with and without mechanical ventilatory assistance. 


^^LTHOUGH postfracture fat embolism 

■^has received much experimental and 
clinical attention over the past decade, 
controversy still exists as to its etiology 
and treatment. The purpose of this paper 
shall not be to dispel such controversy but 
to present a method of evaluation and 
therapy which, in our hands, has met with 
success. 

The literature supports two somewhat 
distinct theories about the etiology of the 
fat embolism syndrome. The most widely 
held is the one advocated by Peltier^-^ and 
others who attribute the syndrome to a 
shower of marrow fat after bone fracture. 
Lehman and Moore,^ among others, have 
countered with the physicochemical hy- 
pothesis that a breakdown of plasma colloi- 
dal fat results in coalescence into large 
circulating globules which become en- 
trapped in the pulmonary vasculature. 

Currently the mechanical theory of Pel- 
tier has more favor than the physicochem- 
ical theory, although it is generally agreed 
that the latter may have a synergistic 
effect. 


Prom the Department of Orthopedic Surgery, 
Ochsner Clinic and Ochsner Foundation Hos- 
pital, New Orleans, Louisiana. 

Reprint requests to Dr. Davis, 1514 Jefferson 
Highway, New Orleans, Louisiana 70121. 


ROBERT C. POWERS, MD 
GERALD L. DAVIS, MD 
New Orleans 

Treatment Method 

We have recently encountered three pa- 
tients with the fat embolism syndrome. 
All were evaluated by monitoring of vital 
signs, serial hemoglobin, hematocrit, and 
arterial blood gas determinations, and 
daily examination of the urine for fat. 
Platelet counts and partial thromboplas- 
tin time were obtained at the acute epi- 
sode of fat embolization. These patients 
were considered to have an increased risk 
of thromboembolic complications and were 
therefore given low molecular weight dex- 
tran (LMWD) (500 ml daily intravenous- 
ly) from the day of admission. When the 
arterial oxygenation deteriorated and al- 
kalosis seemed manifest, sometimes with 
fever, tachycardia or stupor, we adminis- 
tered a large single dose of methylpredni- 
solone (Solu Medrol®) (30 mg/kg) and 
high partial pressure oxygen as required, 
with and without mechanical ventilatory 
assistance. Whole blood, packed red cells, 
and electrolyte fluids were infused as re- 
quired. 

Case Reports 

Patient No. 1 : A 55-year-old Negro man was 

involved in an automobile accident sustaining 
an intratrochanteric fracture of the right hip. 
The hip had previously been involved with asep- 
tic necrosis of the femoral head from a dis- 
placed fracture of the surgical neck of the left 


June, 1974— Vol. 126, No. 6 


205 


POSTFRACTURE FAT EMBOLISM— POWERS, ET AL 


humerus, fractures of the right pubic rami, a 
left Bennett’s fracture, and a fracture of the 
right tibial plateau and right proximal fibula 
with minimal displacement. At admission, the 
patient’s state of consciousness was good and 
there were no neurological or visceral prob- 
lems. On admission, the hemoglobin was 10.8 
grams; blood gases were normal. The fracture 
was splinted and skeletal olecranon and tibial 
traction was applied. Supportive therapy and 
LMWD (500 ml IV every day) were initially 
administered. The patient was given two units 
of whole blood initially. His condition remained 
stable until two days after injury (Day 2) when 
the hemoglobin was 7, arterial p02 was 74.5, and 
arterial pH was 7.47. At that time an additional 
two units of blood were given. On Day 4, the 
hemoglobin was 10, and the patient received two 
units of packed cells and one unit of whole blood 
which brought the hemoglobin to 10.8 by Day 
5. On that day the patient demonstrated ileus 
and vomited a large amount of guaiac-positive 
material. There was no gross blood in the emesis. 
Stool guaiac was negative. He was disoriented 
and obtunded and was given 60 percent oxygen 
via aerosol mask, following which his Pa 02 was 
45 and pH, 7.57. Lipiduria was present. The 
prothrombin time and the PTT were normal; 
platelet count was 148,000; serum lipase was nor- 
mal. The patient was intubated nasotracheally 
and begun on a volume controlled respirator. He 
was given methylprednisolone (30 mg/kg or 2.5 
grams IV). At this time a study was done on 
100 percent oxygen resulting in an arterial par- 
tial pressure of 238.6 mm. On Day 7, the 100 
percent oxygen control resulted in a Pa 02 of 
355 mm. The prothrombin time, PTT, and lipase 
remained normal. The respirator was discon- 
tinued and the patient was continued on oxygen 
by mask until his Pa02 remained above 70 on 
room air. He subsequently underwent a total 
hip replacement for his intratrochanteric fracture 
associated with an aseptic necrotic femoral head 
and an internal fixation of his surgical humeral 
neck fracture. He was discharged from the hos- 
pital after a stay of six weeks. 

Patient No. 2: A 48-year-old Negro man was 

involved in an automobile accident and was 
brought to the Emergency Room with multiple 
injuries. Blood ethanol was .245 mg/100 ml. He 
was semiconscious with a severely comminuted 
fracture of the right femur and multiple lacera- 
tions about the face and upper extremities. Fol- 
lowing debridement and suture of his lacera- 
tions, tibial pin traction was applied. LMWD 
(500 ml every other day) was begun. His ad- 
mission hemoglobin was 15.4 Day 2 after in- 
jury, his hemoglobin was 10.8, pH 7.5, and 
PaOo 69.9. His temperature was 101 F. His 
blood pressure was 290/110 and his pulse was 


90. He was transfused with two units of blood 
resulting in a rise in the hemoglobin to 11.2. As 
serial chest x-rays showed slight widening of 
the arch of the aorta, on Day 4 an aortogram 
and pulmonary arteriogram were done to rule 
out occult aortic laceration. This demonstrated 
an occlusion of the lingular artery. During this 
procedure the patient had to be moved in skele- 
tal traction to an x-ray table. On Day 6, the 
patient was semi-comatose. His hemoglobin was 
11; his Pa02 was 60; pH was 7.57, and pCO, 40. 
Lipiduria was demonstrated. The patient was 
transfused with 500 ml of packed cells and given 
methylprednisolone (30 mg/kg IV) and oxygen 
by aerosol mask at a flow rate of 6 liters /minute. 
On Day 7, the patient had a pH of 7.43 and a 
Pa02 of 71. The urine remained positive for fat. 
On Day 9, the Pa02 was 90 and the pH was 
7.46. The oxygen was discontinued completely 
on Day 10, and the patient was observed five 
days additionally before transfer to a city hos- 
pital for further management of his femoral 
shaft fracture. 

Patient No. 3 : A 52-year-old white woman 

was involved in an automobile accident. She 
sustained a closed comminuted fracture of the 
right femur at the junction of the middle and 
distal thirds, a spiral fracture of the left hume- 
rus, fractures of the right pubic rami, and sev- 
eral fractures of the vertebral transverse pro- 
cess. On admission, her hemoglobin was 12.4. 
The patient was treated by tibial pin traction 
and a hanging arm cast. Low molecular weight 
dextran (500 ml IV every other day) was given. 
The day following admission she was disoriented 
as to time, place, and person. The hemoglobin 
had fallen to 10 grams and the PaO^ was 65; 
the pH was 7.54. The respiratory rate was 
38/min, pulse 100, and temperature 102 F. Blood 
pressure was 102/70. Multiple petechiae were 
present on the anterior chest. The patient was 
transfused with two units of whole blood, given 
60 percent oxygen by aerosol mask, and methyl- 
prednisolone (30 mg/kg IV). Following this the 
Pa02 was 94 with a pH of 7.43 on oxygen. Two 
days following her initial episode of disorienta- 
tion she demonstrated lipiduria which persisted 
for another week. The oxygen was discontinued 
one week after her initial episode. Her fractures 
healed after several months of traction and cast 
immobilization. 

Discussion 

Long bone fractures, especially those of 
the femur, have a high incidence of 
fat embolism and death may abruptly 
follow if the condition is not suspected. 
The syndrome has been thought to occur 
in the first 36 hours after injury but can 


206 


J. Louisiana State M. Soc. 


POSTFRACTURE FAT EMBOLISM— POWERS, ET AL 


occur at any time, particularly in patients 
who must be moved for diagnostic or other 
purposes. 

Diagnosis 

The initial assault of the syndrome is 
upon the pulmonary vasculature produc- 
ing an alveolar-capillary block manifested 
by a low PaOz and alkalotic pH. It is im- 
portant to realize that cyanosis is late in 
arrival when the patient is able to main- 
tain an alkalotic pH despite very low PaOa 
levels and therefore should not be viewed 
as a sign to be anticipated and treated but 
rather prevented. Cerebral dysfunction 
occurs concomitantly with the alkalotic 
hypoxia, and may be manifested by a spec- 
trum of consciousness from lethargy to 
decorticate status. A rise in the pulse and 
respiratory rate and depth is always evi- 
dent and the patient may become hypo- 
tensive. Before the development of these 
signs there generally has been a fall in the 
venous hematocrit of up to 30 percent of 
admission levels. 

The diagnostic procedures most helpful 
to use have been hematocrit determina- 
tions and blood gases. Serum lipase and 
urine fat determinations become positive 
only when the syndrome is well developed. 
Platelet counts may be difficult to obtain 
under some circumstances. 

Treatment 

Whether the fat which aggregates in 
the pulmonary vasculature is of marrow 
or extramarrow origin, the rationale for 
treatment with steroids is well established, 
namely, that of inhibiting the inflamma- 
tory response to free fatty acids released 
in the pulmonary vasculature which in 
turn produces the characteristic alveolar- 
capillary block and also results in de- 
creased pulmonary compliance. Ashbaugh 
and Petty* presented three patients treat- 
ed for fat emboli with corticosteroid drugs, 
5 percent ethanol, and mechanical respi- 
ratory assistance. One patient died; two 
were apparently improved by the use of 
cortisone, 100 mg b. i. d. or t. i. d., by the 
intravenous or intramuscular routes. They 


concluded that steroids were helpful in 
the treatment of fat embolization syn- 
drome. Linscheid, et al,^ reported 15 pa- 
tients over a ten-year period only three of 
whom received steroids in doses compar- 
able to those used by Ashbaugh and Perry. 
Eight of the patients in Linscheid’s series 
survived, and only one of the survivors 
was over 30 years of age. 

Fischer, et al,® in 1971 reported the use 
of methylprednisolone, in a dosage of 125 
mg intravenously initially and 80 mg every 
6 hours thereafter for a three-day period, 
in 13 patients with definite evidence of fat 
embolization syndrome. Improvement was 
noted in the arterial blood gases within 12 
to 24 hours. Our observations also con- 
firm this. On the other hand, it was re- 
ported by LeQuire, et al,^ that prolonged 
small doses of steroids may produce fat 
embolization in rabbits; therefore, we have 
used a large single bolus. 

Alcohol 

Alcohol has been used as an adjunct in 
limiting the effects of lipase but it is 
doubtful as to when this drug has its best 
effect. LeQuire, et al,^ reported that al- 
cohol is contraindicated as a lipase inhibi- 
tor and indeed may have a lipolytic effect. 

Low Molecular Weight Dextran 

In our opinion, low molecular weight 
dextran (LMWD) is of use in preventing 
early and late thromboembolic complica- 
tions and also as an adjunct in the fat 
embolism syndrome. It tends to increase 
plasma volume which may be effective in 
preventing fat embolism. This concept is 
supported by the work of Fuchsig, et al,® 
who removed one-fifth of the blood volume 
from rabbits and injected *®*iodine-labelled 
triolein into the subcutaneous fat pads. 
This deposit was flushed out of the fat 
pad during hypovolemic shock and the 
process was reversed with blood transfu- 
sion. 

Darke® observed 66 patients in a con- 
trolled study where one-half were given 
dextran and one-half dextrose and no de- 
creased incidence in deep venous thrombo- 


JUNE, 1974 — VOL. 126, No. 6 


207 


POSTFRACTURE FAT EMBOLISM— POWERS, ET AL 


sis was found. However, he cited cumu- 
lative studies by other authors of 3,000 
patients who were found to have a statis- 
tically significant lessening of deep ve- 
nous thrombosis. Darke’s patients were 
given only four doses. Rothermel, et al,^" 
studied LMWD in postoperative patients 
and found a high incidence of complica- 
tions; however, half of the complications 
were in the form of seroma or wound 
hematoma. If this complication is elimi- 
nated (as it would be in a non-operative 
patient) , a complication rate of 14 percent 
remains for the patients who received 
LMWD versus 21 percent for the control 
who received no treatment. 

Dextran appears to be as effective as 
Dicumarol in preventing thrombotic com- 
plications. Berquist, et al,“ studied 138 
patients who had femoral neck fractures 
and found the incidence of deep venous 
thrombosis to be 30 percent in both the 
dextran and Dicumarol groups. Bronge, 
et al,’^^ also studied dextran versus Dicu- 
marol and could not find any statistical 
difference in the incidence of deep venous 
thrombosis. Gerbershagen^'^ has reported 
one case of severe fat embolism and men- 
tioned three others treated with LMWD 
infusion who responded by sudden im- 
provement of state of consciousness as well 
as arterial oxygenation. He felt that this 
was a function of improved perfusion and 
lowered cell aggregation properties. 

Heparin 

We have discarded heparin as a thera- 
peutic adjunct along with Ross“ who has 
clearly demonstrated a remarkably in- 
creased mortality rate in rats subjected 
to heparinization and intravenous fat in- 
jections. 

References 

1. Peltier LF : Diagnosis and treatment of fat embo- 
lism. J Trauma 11:661-667, 1971 

2. Peltier LF : Fat embolism. Orthop Clin North Am 
1:13-20, 1970 

3. Lehman EP, Moore RM : Fat embolism: including 
experimental production without trauma. Arch Surg 
14:621-662, 1927 

4. Ashbaugh DG, Petty TL: The use of corticoste- 
roids in the treatment of respiratory failure associated 
with massive fat embolism. Surg Gynecol Obstet 123 :493- 
500, 1966 


5. Linscheid RL, Dines DE: The fat embolism syn- 
drome. Surg Clin North Am 49:1137-1150, 1969 

6. Fischer JE, Turner RH, Henidon JH, et al : 
Massive steroid therapy in severe fat embolism. Surg 
Gynecol Obstet 132:667-672, 1971 

7. LeQuire VS, Hillman JW, Gray ME, et al : Clinical 
and Pathologic Studies of Fat Embolism. Chapter 2 in, 
American Academy of Orthopedic Surgery Instnictional 
Course Lectures, Vol 19, St. Louis, Mosby, 1970, pp 12-35 

8. Fuchsig P, Brucke P, Blumel G, et al : A new 
clinical and experimental concept of fat embolism. New 
Engl J Med 276:1192-1193, 1967 

9. Darke SG : Iliofemoral venous thrombosis after 
operations on the hip — A prospective controlled trial 
using dextran 70. J Bone Joint Surg 54B : 615-620, 1972 

10. Rothermel JE, Wessinger JB, Stinchfield FE: 
Dextran 40 and thromboembolism in total hip replace- 
ment surgery. Arch Surg 106:135-137, 1973 

11. Bergquist E, Bergquist D, Bronge A, et al : An 
evaluation of early thrombosis prophylaxis following frac- 
ture of the femoral neck. A comparison between dextran 
and dicumai’ol. Acta Chir Scand 138 :689-693, 1972 

12. Bronge A, Dahlgren S, Lindquist B: Prophylaxis 
against thrombosis in femoral neck fractures — a com- 
parison between dextran 70 and dicumarol. Acta Chir 
Scand 137:29-35, 1971 

13. Gerbershagen HU: Fettembolie: Therapie mit 

niedrig viscosem Dextran. Anaesthesist 21:23-25, 1972 

14. Ross AP: The effect of heparin in experimental 
fat embolism. Surgery 66:765-767, 1969 


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seeing 18,000 patients per year. 200-|- bed 
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Contact T. W. Davis, K/I.D. or W. H. Brown, M.D., 
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208 


J. Louisiana State M. Soc. 



\Iedical Grand Rounds 

from 

Touro Infirmary 


Secondary Syphilis 


Dr. Ignatius Thomas A 41-year-old 
divorced white man had been in good 
health until seven days prior to admis- 
sion when he became ill with fever, 
malaise, headache, a dull ache all over 
the body, especially in the lumbar re- 
gion, sore throat and a generalized skin 
rash. He stated that he had been 
treated for gonorrhea with penicillin five 
times in the past, the most recent occasion 
being about eight months ago. He gave a 
history of a single episode of grand mal 
seizures five years ago since which time 
he had been taking Dilantin. 

He presented as a white man in no 
acute distress (oral temperature 102°, 
pulse 80 per minute, respirations 18 per 

Intern, Touro Infirmary. 

June, 1974 — Vol. 126, No. 6 


Edited by SYDNEY JACOBS, MD 
New Orleans 

minute and blood pressure 120/80) with 
reddish brown maculopapular lesions, 
varying in size from 2 mm to 5 mm, over 
his face, chest and abdomen and lower 
extremities. The lesions were dry and 
nonpruritic. He also exhibited bilateral 
painless and non-tender lymph node en- 
largement. 

Dr. Sydney Jacobs Dr. Thomas, 
what was your admission diagnosis ? 

Dr. Thomas : Since he had been treat- 
ed with penicillin in the past for gonor- 
rhea (and had had five clinical epi- 
sodes), we diagnosed secondary syphilis, 
despite lack of history of chancre. His 
pertinent laboratory findings were : posi- 

Chairman, Department of Medicine, Touro 
Infirmary; Clinical professor of medicine, Tulane 
University School of Medicine. 


209 



MEDICAL GRAND ROUNDS^Touro Infirmary 


tive Kolmer blood reaction and positive 
VDRL test in dilution of 1 :128, with pos- 
itive reactions when cerebrospinal fluid 
was tested. Albuminuria and abnormal- 
ly high blood content of alkaline phos- 
phatase as well as of hepatic enzymes 
suggested visceral involvement. 

He was given penicillin, 1.2 million 
units, in each buttock on the fifth day 
of hospitalization. Following this he had 
a worsening of his symptoms, spiking 
fever and with generalization of the skin 
rash ; but this improved in about 24 to 36 
hours. Since that time, he has been 
asymptomatic. The albuminuria sub- 
sided, and the liver function test results 
became normal. He was given additional 
penicillin, 1.2 million units, in each but- 
tock, seven days after the first treat- 
ment. The plan is to give sufficient peni- 
cillin to a total of 9 million units and to 
observe him as an outpatient, perform- 
ing a VDRL test every six months for 
two years. The transient nephritis and 


hepatitis are quite usual for secondary 
syphilis and promptly abate with treat- 
ment. 

Dr. Jacobs: When Treponema pal- 

lidum invades a host, it incites formation 
of at least two types of antibodies: those 
to the organisms themselves (detected 
by treponemal tests employing antigens 
derived from T. pallidum) and those to 
the interaction with tissues (called re- 
agins). Reagin usually appears in the 
serum four to six weeks after infection 
or one to three weeks after appearance 
of the primary chancre. We try to de- 
tect the presence (and amount) of re- 
agin by either a flocculation test such as 
the Venereal Disease Research Labora- 
tory (VDRL) test or by a complement- 
fixation test such as the Wassermann 
reaction. The original Wassermann re- 
action used spirochetes for antigen. This 
is no longer done. Most laboratories use 
beef heart as a source of antigen al- 
though the test is still popularly called a 



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210 


J. Louisiana State M. Soc. 



MEDICAL GRAND ROUNDS — Touro Infirmary 


“Wassermann test”. Although nonspe- 
cific, ie, the test may be positive in con- 
ditions other than syphilis, the test is 
reasonably sensitive in that it is usually 
positive in the course of a state of syph- 
ilis. Obviously for screening purposes, 
we use a sensitive test, but for the differ- 
ential diagnosis we need a specific test. 
The Treponema Immobilization Test 
(TPI) of Nelson and Mayer is specific 
but is too difficult technically and too 
expensive for other than research em- 
ployment. The Fluorescent Antibody 
Test (FTA) is an improvement over the 
TPI in many regards. It involves expos- 
ing the serum of a syphilis suspect to 
a Treponema pallidum preparation ; in 
this reaction, if there are antibodies in 
the serum to spirochetes, they will pre- 
cipitate on the treponema. The prepara- 
tion is stained with fluorescin-tagged 
anti-human globulin which attaches to 
the globulin-coated treponemas and flu- 
oresces when viewed by ultraviolet light. 
A positive FTA test removes from con- 
sideration a biologically false-positive 
reaction, ie, one produced by a non-syph- 
ilitic state capable of inciting production 
of reagin. The FTA test is specific but 
not sufficiently sensitive and, therefore, 
fails to detect some instances wherein 
unequivocally syphilitic infection has oc- 
curred. By preparing an antigen from 
the non-pathogenic Reiter spirochete and 
by absorbing out the common antigens, 
a Fluorescin Treponemal Antibody Ab- 
sorbed (FTA-ABS) test evolved which is 
specific, sensitive, low in cost and in 
technical requirements so as to be clini- 
cally available. If the FTA-ABS test is 
positive, what does that indicate? 

Dr. Luis Pena:^‘=^ There is no question 
that the patient has syphilis. 

Dr. Jacobs: Does that indicate that 
the patient has active syphilis ? 

Dr. Pena: Well, most probably, or in- 
adequately treated syphilis. 


(c) First year medicine resident, Touro Infir- 
mary. 


Dr. Kenneth L. Cohen The adequa- 
cy of treatment does not have anything 
to do with the FTA-ABS. The fact that 
the FTA-ABS is positive means that he 
has syphilis. Whether or not he has been 
adequately treated is determined by 
looking at his medical record or by ask- 
ing him. Where there is a question, you 
have to repeat the treatment. 

Dr. Jacobs: Is it not true that a man 
can have a positive VDRL and a positive 
FTA-ABS, be properly treated, and still 
retain a positive fluorescent test? 

Dr. Cohen: I believe that FTA-ABS 
lasts a lifetime. Once positive, it never 
reverts to negative. 

Dr. Jacobs : Does this man have a pos- 
itive FTA? He had a positive VDRL. 
Was he treated for gonorrhea five times 
adequately? Were these reinfections 
with gonorrhea and not exacerbations of 
an original infection? How do we know 
that the FTA became positive with this 
illness and that it had not been positive 
for as long as five years? 

There was a time when we used to 
argue that once infected with syphilis, 
one is always infected with syphilis and 
could not be reinfected. But with the 
use of penicillin, I think that the prevail- 
ing belief is that one can get a reinfec- 
tion with syphilis. Even if you get a re- 
infection with syphilis, there is a sero- 
logic scar of that infection five years 
back of a positive FTS. So we must not 
rely upon the serological examination as 
incontrovertible evidence of a sequence. 
A good history is much more important 
in that regard. 

Dr. Thomas : His VDRL is positive in 
serum dilution 1 :128, which exceeds the 
diagnostic level of 1 :32. 

Dr. Pena : With secondary syphilis, it 
is common to find hepatitis and nephritis 
featured by elevation of the alkaline 
phosphatase but normal levels of serum 
bilirubin. 


Dermatology consultant, Touro Infirmary. 


June, 1974 — VoL. 126, No. 6 


211 


MEDICAL GRAND ROUNDS— Touro Infirmary 


Dr. Shahrokh SodagarC®) In the ab- 
sence of any neurological finding, why 
did you examine the cerebrospinal fluid ? 

Dr. Pena: If the spinal fluid is nega- 
tive, you have to give only one injection 
of 2.4 million units benzathine penicil- 
lin; but if the spinal fluid is positive, you 
have to prolong the treatment with ben- 
zathine penicillin-G three weeks. 

Dr. Jacobs: In syphilis, the spirochete 
circulates throughout the body, so that 
treatment of the primary lesion or even 
of the secondary lesion, isn’t a matter of 
saving a man’s life. Saving a man’s life 
from syphilis depends more on preven- 
tion of brain damage and of cardiac 
damage than anything else. 

The development of solid immunity 
can be postponed by subcurative doses 
of antimicrobial therapy. This explains 
the reappearance of manifestations of the 
acute phases of the disease. We must 
know at the very beginning whether this 
man has evidence of cerebrospinal syph- 
ilis, which is a pretty deadly thing, or 
whether apparently the treatment has 
been started at a time before there was 
real evidence of involvement of the cen- 
tral nervous system. Dr. Cohen, do you 
have any comments on that ? 

Dr. Cohen : It is not customary to ex- 
amine the cerebrospinal fluid in the sec- 
ondary stage. More often we examine 
the cerebrospinal fluid 9 to 12 months 
after therapy to detect residual sympto- 
matic neurosyphilis. Unless we demon- 
strate normal spinal fluid, we cannot 
properly classify his syphilis as “latent”. 
Latent syphilis means that there are foci 
of spirochetes in areas not accessible to 
diagnostic search ; therefore, no abnor- 
malities are found on physical examina- 
tion, but there can be elicited positive re- 
sults with blood tests such as the VDRL 
and the FTA ABS. Central nervous sys- 
tem foci are not inaccessible ; they reveal 
themselves in the cerebrospinal fluid 
analysis. Since your patient’s spinal fluid 

First year medicine resident, Touro Infir- 
mary. 


is positive and the neurological examina- 
tion is negative, he has asymptomatic 
neurosyphilis with all the risks of pro- 
gressing into late latent syphilis. This is 
why most authorities would recommend 
giving 2.4 million units of V-Cillin week- 
ly times four. This patient has a perfect- 
ly classical case of secondary syphilis re- 
plete with nephritis, hepatitis, adenop- 
athy, fever and syphilitic reaction. Le- 
wandowsky’s law states that in the 
course of untreated syphilis, no patient 
can go through the same stage twice, 
and strictly that means chancre immu- 
nity; however, there is such a thing as 
recidivating secondary syphilis. This 
man, particularly if he becomes VDRL 
negative, is completely capable of getting 
syphilis again, ten times over, as long 
as he gets treated right away, because it 
takes years of untreated latency, for this 
immunologic machinery to come into 
play. A patient with untreated secon- 
dary lues may have years of latency be- 
fore tertiary syphilis occurs. At that 
point, of course, reinfection would not 
manifest as secondary lues. It would 
manifest as a serological relapse. 

Dr. Sodagar: Two days ago, I had a 
woman in the clinic, who had positive 
VDRL and Kolmer-Wassermann in 1970, 
and she told me that she never had sex 
until one year ago. So it is possible some- 
times the chancre may not be recognized 
by the patient. 

Dr. Cohen : The chancre may not oc- 
cur in a site where it can be easily seen. 
Women acquire it, and in homosexual men 
it is probably often unrecognized. 

Dr. Pena: How accurate is the dark 
field in dry skin lesion? 

Dr. Cohen : It is very inaccurate and 
usually negative. If you soak a secon- 
dary syphilitic lesion, it will almost al- 
ways become dark field positive in two 
to three days. The World Health Organi- 
zation has no evidence at all that there 
is such a thing as a penicillin-resistant 
Trepo7iema pallidum. I should add at this 


212 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS^ — Touro Infirmary 


point that syphilis also exists in many 
parts of the world in endemic fashion, 
that is to say, as a nonvenereal infection. 
Some people believe that endemic syph- 
ilis exists in New Orleans, and I would 
not question it. Lastly, I believe that 
many people exaggerate the infectious- 
ness of the lesions of secondary syphilis. 
These, of course, do contain spirochetes ; 
but if they are dry, they are apt not to 
be contagious because they have to be 
moist to transmit the organisms. 

Editor’s Note : For the year 1971, New 
Orleans was rated as number ten among 
major USA cities in reporting of primary 
and secondary syphilis. It is interesting 
to recall that in the United States at 
large in the year 1949, almost 80 cases 
per 100,000 population were reported ; 
but that by 1959, penicillin therapy had 
reduced this figure to lower than 4/100,- 
000. By 1965, this rate had escalated to 
almost 11/100,000. As early as 1962, 
Danehower had published a paper en- 
titled “Penicillin Fallout — Menace or 
Manna?” in which he observed that the 
“indiscriminate” use of penicillin had re- 
duced the syphilis attack rate by 93 per- 
cent because it reached unknown num- 
bers of unrecognized cases. When physi- 
cians recognized some of the unwanted 
effects of using penicillin without sharp- 
ly defined indications, the syphilis attack 
rates rose. Deploring the lack of a “prac- 
tical way of accomplishing a near-simul- 
taneous mass prophylaxis of the entire 
population so as to deprive every trep- 
onema of its very host and potential 
host,” Danehower offers a challenging 
suggestion that the next “safe, conven- 
ient, inexpensive spirocheticidal drug . . . 
(be) properly distributed before the pop- 
ulation has had time to become allergic 
to it and before organisms have had time 
to develop resistance to it. Such pro- 
cedure could conceivably eliminate the 
great pox”.^ 

Reference 

1. Danehower WF: Penicillin fallout and infectious 

syphilis. Med Clin N Amer 48:747, 1964 


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June, 1974 — Vol. 126, No. 6 


213 





LAKE MARINA 
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The New Standard tor Racquet Faci liti es in 
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Our roster is now open to a limited number of charter members. Inquiries 
should be mailed to 728 NBC Building or phone 588-9343 for information. 


LAKE PONTCHARTRAIN 


214 


J. Louisiana State M. Soc. 



uuiotog.^ 


Eosinophilic Granuloma of Skull 

SEYMOUR FISKE OCHSNER, MD 

New Orleans 


■pOSINOPHILIC GRANULOMA, first 
identified as a characteristic lesion by 
Lichtenstein and Jaffe^ in 1940, is consid- 
ered a benign granulomatous process of 
uncertain cause. It is generally believed to 
be one part of a spectrum of lesions that 
are grouped as variations of histiocytosis x. 

The skull is a common site of involve- 
ment of eosinophilic granuloma of bone. 
The lesion has a characteristic radiograph- 
ic appearance. It is usually 2 or 3 cm in 
diameter, is sharply defined, and involves 
both inner and outer tables of the involved 
portion of the skull. There is usually no 
marginal sclerosis (which would be more 
suggestive of epidermoid lesion of skull) 
and no granularity in the area of radio- 
lucency (which would be more suggestive 
of hemangioma of bone). Sometimes one 
finds a bevelled appearance of part of the 
margin due to more extensive involvement 
in either the inner or outer table of bone 
by the destructive process. Occasionally, 
a central “button of bone” is seen within 
the radiolucent area. The bone surround- 
ing the lesion is usually normal, showing 
neither periosteal reaction nor increased 
vascularity. Although the bony lesions 
may mimic malignant tumors, the diag- 
nostic radiologist should recognize the 
benign potential.^ 

Report of a Case 

A 7-year-ald schoolgirl was seen at Ochsner 
Clinic in May of 1967, after a two-month history 
of tenderness and intermittent pain in the left 
occipital area. The patient’s mother noticed a 
slight “bump” on the child’s head. Radiographs 
of skull (Fig lA and B) revealed a 1.8 cm oste- 
ol 3 Ttic area in the left posterior parietal area. It 
was sharply defined, slightly irregular in contour. 


From the Department of Radiology and Radia- 
tion Therapy, Alton Ochsner Medical Foundation 
and Ochsner Clinic, New Orleans. 


and involved both tables of the skull. The edges 
were slightly bevelled and not sclerotic. The ra- 
diographic diagnosis was probable eosinophilic 
granuloma. Blood examinations were normal. 
There was no fever or evidence of other osseous 
lesions. On July 10, 1967, a biopsy was done 
under general anesthesia. Histologic study indi- 
cated the lesion was an eosinophilic granuloma. 



Fig lA. Frontal radiograph shows osteolytic 
area in left side of skull. (May 25, 1967) 



Fig IB. Lateral radiograph indicates that the 
lesion is in posterior parietal area. (May 25, 
1967) 

In six radiation treatments, between July 17 
and July 28, 1967, 900 roentgens (skin dose) 
were given. Factors: 5x5 cm portal, H.V.L. 3 mm 
Cu, F.S.D. 50 cm, and six fractions of 150 R. No 


June, 1974— Vol. 126, No. 6 


215 


RADIOLOGY PAGE 



Fig 2. Lateral radiography, four months 
after dose of 900 R, reveals that the eosinophilic 
granuloma is almost completely healed. 


adverse reaction to this orthovoltage therapy oc- 
curred, although subsequently the patient suf- 
fered temporary (3 month) local alopecia of the 
treated area of scalp. In November of 1967, the 
patient had no complaints and radiographs of 


skull (Fig 2) indicated that the lesion was almost 
totally healed. We understand she has remained 
well over five years. 

Comment 

Treatment of eosinophilic granuloma re- 
mains unsettled. McGavran and Spady^ 
reviewed 28 cases of bone involvement. 
Improvement followed surgery, irradia- 
tion, and in several cases, no specific ther- 
apy. If irradiation is used, a low dose is 
advisable. This patient was apparently 
cured by delivery of only 900 roentgens 
(skin dose) . 

References 

1. Lichtenstein L, Jaffe HL: Eosinophilic granuloma 

of bone, with report of case. Am J Pathol 16:595-604, 
1940 

2. Ochsner SF : Eosinophilic granuloma of bone, ex- 

perience with 20 cases. Am J Roentgenol Radium Ther 
Nucl Med 97:719-726, 1966 

3. McGavran MH, Spady HA: Eosinophilic granuloma 
of bone, study of 28 cases. J Bone Joint Surg 42A:979- 
992, 1960 


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216 


J. Louisiana State M. Soc. 





Editorial 


Annual Meeting of the State Society 


The 1974 annual meeting of the Louisi- 
ana State Medical Society was held in 
beautiful facilities, in an atmosphere of 
masterful hospitality, in one of Louisiana’s 
great cities. Lake Charles. The hotel ac- 
commodations, the food, and the entertain- 
ment provided by the Calcasieu Medical 
Society were excellent. The members, 
without exception, are looking forward to 
future meetings which will be hosted by 
this West Louisiana society. 

The House of Delegates, attempting to 
express the voice of the practicing physi- 
cian, brought to the floor a variety of reso- 
lutions. These, along with various com- 
mittee reports, were received and debated 
vigorously. In the final vote, the wisdom 
of the majority seemed to express worthy 
and carefully worded policies and activi- 
ties for the ensuing year. At the conclu- 
sion of debate on each and every issue, one 
was impressed with the depth of rugged 
independence, the general conservatism, 
and the almost unanimous opposition to all 
governmental programs which by legisla- 
tion would in any way interfere with the 
traditional patterns of delivery of patient 
medical care. 

Our immediate past president, James 
Stewart of Orleans Parish, in terminating 
his year of service, could not but feel the 
admiration and gratitude of every dele- 
gate, for a job well done, one which each 
of us realized was done with great sacri- 
fice to family, to patient, and to income. 
Dr. Stewart, as have all past presidents, 
gave much to our society and for which 
our society in turn gave so little. Perhaps 
this is not the time or place to suddenly 
veer into the subject of partial reimburse- 
ment for our president’s loss of income; 
however, this is a matter which must be 
faced if we are to maintain leadership 


such as we have been able to provide in 
the past. 

Dr. H. H. Hardy of Rapides Parish ac- 
cepted from Dr. Stewart the reins for this 
year’s leadership. He will bring to the 
society his ability as a seasoned warrior, 
having served at almost every level of or- 
ganized medicine. As speaker of the House 
of Delegates, he conducted a forum for 
debate which was considered fair and un- 
biased. As a member of the JACH, he con- 
tinues to serve with distinction and is rec- 
ognized as having the honesty and innate 
ability to reflect the opinion of the vast 
majority of the practicing physicians in 
Louisiana — regardless of his own person- 
al views on any given assignment. 

Our president-elect, F. Michael Smith of 
Lafourche Parish, is known for his varied 
assignments in medicine in which he has 
served with ability. He was largely re- 
sponsible for the Special Projects Commit- 
tee. For the past eight years, this group 
has read and studied, in detail, the pro- 
posed federal legislation on health care; 
and several times they have circulated 
early warnings to Louisiana physicians on 
socioeconomic matters. He is a reader of 
fine print when it comes to proposed legis- 
lation. While others are getting their in- 
formation from news releases, Mike is in 
there seeing for himself. He always does 
his groundwork. 

The society is indeed fortunate to have 
such outstanding leaders during this dif- 
ficult period, in which PSRO, HMO, NHI, 
and many other alphabetic symbols of 
governmental intervention and control are 
already law or constitute proposed legisla- 
tion. They deserve our utmost support, 
input, and above all our thankfulness for 
their many sacrifices. 


June, 1974 — Vol. 126, No. 6 


217 



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218 


J. Louisiana State M. Soc. 


-S 


oci oecon omic 



By LEON M. LANGLEY, JR. 


HEW Proposes New Payment Plan Under Medicare. HEW Secretary, Caspar W. 
Weinberger, announced last Monday a proposal under which Medicare would 
“pay for services not covered by the law either because they were not ‘reason- 
able or necessary’ or ‘involved custodial care’ The proposed regulations are 
based upon section 213 of P.L. 92-603 which deals with the reimbursement of 
patients, providers and practitioners (when rights have been assigned) with re- 
spect to the reimbursement of services found to be unreasonable or unnecessary, 
or were custodial in nature. Under the proposed system, the Medicare system 
would pay for the services when neither the person who received the service nor 
the person who furnished it could reasonably be expected to know if the services 
were covered. If the provider of services or the physician knew, or could reason- 
ably be expected to know, that the services were not covered, then neither Medi- 
care nor the beneficiary would be liable for payment. Presently, if the benefi- 
ciary were charged for the non-covered service, Medicare would repay the bene- 
ficiary and charge the amount to the provider of services. The proposed rule would 
establish a system of presumption under which certain providers would be pre- 
sumed to lack knowledge of non-coverage in specific cases, in the absence of evi- 
dence to the contrary. 

There Were 9,845 More Physicians in the United States at the end of 1973 than in the 
previous year, AMA’s Center for Health Services Research and Development re- 
ported. The 1973 final figure in AMA’s Masterfile of Physicians was 366,379, 
compared to 356,534 at the end of 1972. A census of the physician population 
was conducted last year, and all physicians’ biographical and activity records 
were brought up to date. Physicians are classified in the Masterfile by the num- 
ber of hours spent in the categories of professional activities, specialization and 
type of employment. 

The Number of Physicians Providing patient care rose from 292,210 in 1972 to 295,- 
257 last year. Of these, 201,435 were office based and 93,822 were hospital 
based. The number listing their major activity as medical teaching rose from 
5,636 in 1972 to 6,183, and those engaged in administration moved from 11,074 
to 11,959. The number engaged in research dropped from 9,290 in 1972 to 8,332 
last year. The number of physicians listed as inactive was 22,624 and those that 
could not be classified numbered 13,744. The addresses of 5,644 physicians were 
unknown. 

The Number of General Practitioners decreased from 55,348 in 1972 to 53,946 last 
year. Physicians in “medical specialties” rose to 86,924 last year, compared to 
84,153 in 1972; those in “surgical specialties” rose to 91,549, compared to 91,058 
the previous year. The number classified in “other specialties” was 91,948, an in- 
crease of 1,604. 


c=an=> 


June, 1974— Vol. 126, No. 6 


219 


Now there’s a way to appear in court 
without ever ieaving your practice: 

Videotape. 


Testifying as an expert witness 
often means hours of waiting in court, 
hours you could better spend with 
your patients. 

In the past, your only alternative 
was a deposition presented to the 
court in written form, with charts or 
other materials to illustrate your 
testimony. And even after giving 
your deposition, you had to spend 
more time reviewing the transcript, 
making corrections. No professional 
can afford to give testimony that’s 
less than totally accurate. 

All in all, it was a rather unsatis- 
factory means of communication. 

Times have changed. Videotape 
is now accepted by federal and cer- 
tain state courts for use in expert 
witness depositions as well as court- 
room reporting. 

Video Court Reporters™ can re- 
cord your statement in your own 
office, in one of our own suites or 
wherever you find it convenient. 
Whenever you find it convenient. 

And a videotaped 
statement is complete 
and 1 00% accurate the 
first time. With no time- 



consuming review and corrections. 

Visual aids can be recorded on 
tape as you explain them. You can 
point out particular areas on a chart 
or X-ray, for example, as you refer to 
them. And there is no need for 
special lighting. 

Even though you may not an- 
tic ipate having to testify as an expert 
witness, you should be prepared. 
Videotape can make your testimony 
as complete as if it were given in 
person, in court. Yet it’s recorded at 
your convenience. 

Weigh the advantages of 

videotaped depositions. And 
when you’re asked to testify, 
specify videotape. 


NC 


Home Office: 207 Richards Building, New Orleans, Louisiana 701 12, (504) 586-0076 


Copyright VCR 1974 


220 


J. Louisiana State M. Soc. 


Or g anization ^ecti on 


The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


ABSTRACTED MINUTES 

HOUSE OF DELEGATES 

LOUISIANA STATE MEDICAL SOCIETY 

Lake Charles, Louisiana 
May 5-7, 1974 

Minutes 

1973 House of Delegates (Special and Regular 
Sessions) — adopted as printed. 

Executive Committee since 1973 Annual Meet- 
ing — adopted as printed. 

Special Order 

Invocation — Dr. F. P. Bordelon, Jr. 

Salute to Flag led by Chairman. 

New Delegates recognized. 

Roll of Deceased Members read] period of si- 
lence in memory. 

Remarks of Chairman’, particular reference to 
parliamentary procedure. 

Introduction of guests. 

Recognition of Assistant Secretary-Treasurer’, 
announcement of retirement and presentation of 
gift. 

Talk by Dr. Gerald Weiss, delegate to Consti- 
tutional Convention’, commended for activity. 

Announcement that Dr. Malcolm C. Todd, Pres- 
ident-elect of the American Medical Association, 
would address the House of Delegates at the 
luncheon. 

Comments and highlights of year given by 
President. 

Conference with Senator Russell Long an- 
nounced. 

Letter from Mrs. E. L. Leckert in re election 
of Dr. Leckert to Hall of Fame. 

Message to be sent to Dr. C. Grenes Cole, Sec- 
retary-Treasurer Emeritus, in re absence from 
meeting; also birthday greetings in July. 

Message to be sent to Dr. C. F. Bellone, Coun- 
cilor of First District, in re absence from meeting. 

Announcement of scientific exhibit awards — 
First place: Levator Resection for Blepharopto- 
sis, Robert A. Schimek, MD. Second place: Sur- 
gical Treatment of Coronary Artery Disease, 
Charles W. Pearce, MD, White E. Gibson, III, 
MD, and Rudolph F. Weichert, III, MD. 

Greetings from President and Past President 
of LSMS Auxiliary. 

Thanks expressed by students for privilege of 
attending meetings and membership in Society. 


Thanks to Chairman and Vice-Chairman of 
House of Delegates for handling of meeting. 

Reports Without Recommendations 
(Accepted as presented) 

Officers: Secretary-Treasurer (including sup- 
plemental financial report and recognition of 
Assistant Secretary-Treasurer) ; Board of Coun- 
cilors; Councilors of First, Second, Third, Fourth, 
Fifth, Sixth, Seventh and Eighth Districts; Com- 
mittees: AMA Education and Research Founda- 
tion; Budget and Finance; Diabetes; Disaster 
Medical Care; Drug Abuse and Alcoholism; 
Emergency Room Care; Environmental Health; 
Federal Legislation; Fragmentation of State 
Government Health Services; Health Care Costs; 
Hospitals; Industrial Health; Liaison with Lou- 
isiana State Bar Association; Louisiana State 
Medical Form Program and Health Insurance 
(Chairman asked that word “exclusively” with 
regard to use of form be changed to “extensive- 
ly”) ; Maternal Welfare; Medical Defense; Med- 
ical Testimony; Medicine and Religion; Nuclear 
Medicine; Public Relations; Regional Medical 
Programs; Scientific Program; Technical Ser- 
vices; Tetanus; Woman’s Auxiliary (Advisory). 

Other Reports: Committee on Rules and Order 
of Business; AMA Delegates (one containing 
recommendations reported with other reports 
containing recommendations) ; AMA Alternate 
Delegates; Legal Counsel (see reports with rec- 
ommendations) ; Louisiana State Board of Med- 
ical Examiners; LAMPAC. 

Report of Executive Committee 

I. Matters referred to Executive Committee 
by 1973 House of Delegates: a. Recommendation 
of Committee on Medical Defense in re measures 
aimed at preventing claims and supplying aid to 
defendants — discussed and information to be 
carried in Journal, b. Resolution No. 610 (Med- 
ical Care in Jails and Correctional Institutions) 
— material available through AMA. c. Resolu- 
tion No. 616 (Long Range Planning Committee) 
— -requests for suggestions carried in CAP- 
SULES. d. Request of LAMPAC Board that 
LSMS Executive Committee appoint a voting 
member at large to Board of LAMPAC and that 
the LSMS elect each year a board member of 
LAMPAC to Executive Committee of LSMS — 
Dr. Redfield Bryan elected to represent LSMS 
on LAMPAC Board; election of LAMPAC repre- 


JUNE, 1974— VOL. 126, No. 6 


221 


ORGANIZATION SECTION 


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EUREKA HOMESTEAD SOCIETY 


sentative on Executive Committee not approved 
(see report of Committee on Charter, Constitu- 
tion and By-Laws), e. Preparation of Abortion 
Act — no action at fiscal session, f. Continuation 
of in depth study of PSRO — Executive Commit- 
tee and component societies kept informed, 
g. Special Resolution in re Executive Director of 
LSMS — referred to Committee on Long Range 
Planning (see report of Committee). 

II. Matters referred by Executive Committee 
to 1974 House of Delegates: a. Recommendation 
in re increase in dues to $100.00 a year — ap- 
proved. b. Opposition to content of HR 12053 
(see Resolution No. 705). c. Suggested amend- 
ments to Charter, Constitution and By-Laws in 
re LAMPAC Board member on Executive Com- 
mittee ; dues exempt membership for members 
after age 70; clarification in re collection of dues 
by component societies and affiliate membership 
for oral surgeons (see Report of Committee on 
Charter, Constitution and By-Laws), d. Proposed 
amendment to By-Laws to include provisions for 
Professional Liability Review (see report of Le- 
gal Counsel), e. Recommendation of Dr. C. 
Grenes Cole as recipient of LSMS Distinguished 
Service Award — approved, f. Recommendation of 
Dr. George H. Hauser for Honorary Membership 
— approved, g. Change of Congressional Districts 
in By-Laws to Medical Districts (see report of 
Committee on Charter, Constitution and By- 
Laws) . 

Other Reports With Recommendations 
(Amended recommendations worded as adopted) 

Past Presidents Advisory Council — submission 
of resolution of commendation of Mr. Percy J. 
Landry, Jr. — adopted. 

President: Following recommendations adopt- 
ed: 1: This Society continue to oppose PSRO 

and other similar governmental schemes to inter- 
fere with the practice of medicine. 2. We con- 
tinue to strengthen our political arm, LAMPAC, 
and request the Chairman of LAMPAC to render 
a report at each meeting of the Executive Com- 
mittee and at each Annual Meeting of the House 
of Delegates. 3. The Secretary-Treasurer, in the 
interest of unity, again send to the officers of all 
component societies a special reminder about 
Division Five, Chapters XXII and XXIII of our 
By-Laws. 4. We maintain a close liaison and 
working relationship with other professional or- 
ganizations having objectives similar to our ovm. 

AMA Delegate (GWP) : 1. The LSMS con- 
tinue to provide leadership in repeal of Section 
249F of Public Law 92-603. — adopted. 2. Con- 
gressman John Rarick of the Sixth Congressional 
District of Louisiana be sent a letter of apprecia- 
tion for his efforts to repeal by introduction of 
legislation in the U.S. Congress in 1973. — adopted. 

Legal Counsel: Amendment to By-Laws to in- 

J. Louisiana State M. Soc. 



ORGANIZATION^ SECTION 


elude Professional Liability Review — approved. 
Discussion in re LAMP AC Board member on 
Executive Committee and By-Laws of component 
societies, legislative matters and other subjects 
of interest. 

Committees 

Aging: 1. Implementation of President’s pro- 
gram for upgrading nursing homes should con- 
tinue with the cooperation of Federal, State and 
private sectors of Medicine and cost of inspec- 
tion be the full responsibility of Federal and 
State agencies — rejected. 2. The State Medical 
Society be made aware of problems of under- 
nutrition and diseased states arising from same 
and that it lend its support to the State Health 
Department, State Council on Aging and other 
agencies toward improving the health and well 
being of aged in Nursing Homes and Homebound 
individuals. — rejected. 3. The development of 
Health Maintenance Organization services to 
geriatric patients is contrary to the best interest 
of the patient as well as the private practitioners, 
clinics, hospitals and Organized Medicine and its 
concept is another third party interference in the 
practice of medicine — referred back to Committee 
for re- wording. 4. The Veterans Administration 
concept of improving quality of nursing home 
care and techniques to help older people remain 
independent be used as a guideline for studying 
their systems to improve private and State nurs- 
ing home sectors — rejected. 

Aid to Indigent Members : 1. In order to estab- 
lish criteria for eligibility for aid from the Com- 
mittee on Aid to Indigent Members those receiv- 
ing aid be destitute, unable to practice and are 
recommended by their local medical society — re- 
ferred, with suggestions, back to Committee for 
re-wording. 

Areawide Planning: 1. The Committee on 

Areawide Planning urges the LSMS House of 
Delegates to go on record as opposed to the con- 
tent of HR 12053 as it stands at the present time. 
— received for filing. 

Cancer (Commission) : 1. Members of the So- 
ciety avail themselves of the Dial Access System 
Service provided by the University of Texas Sys- 
tem Cancer Center through the Southern Medical 
Association Cancer Education Service; catalogue 
of subjects offered and the supplemental listings 
of additional topics issued every 60 days can be 
obtained by dialing 1-800-231-6970 — approved. 
2. Appointment of members of the Cancer Com- 
mission provide for representation of the several 
Louisiana Congressional Districts in order to bet- 
ter learn what is being thought and done through- 
out the State and to better assure diffusion and 
implementation of cancer-related policies and pro- 
grams developed statewide — approved. 3. Mem- 
bers of the Society be urged to renew and ag- 
gressively stimulate lay educational activities and 


programs which have, in some areas of the State, 
shown evidence of flagging interest — approved. 
4. Members of the Society be informed of the edu- 
cational and training facilities available through 
the Tulane Clinical Cancer Research Center, as 
set forth in the main body of this report — re- 
ferred, with suggestion, back to Committee for 
rewording. 5. The sum of $500.00 be budgeted for 
use of the Cancer Commission as may be needed 
during 1974-75 — referred to Committee on Bud- 
get and Finance and recommendation of that 
Committee to approve — adopted. 

Charter, Constitution and By-Laws: 1. Amend- 
ments (wording only) to change congressional 
districts to medical districts (Charter — Article 
V, first sentence — approved by vote of general 
membership), (By-Laws — Chapter XIII, first 
paragraph and Section 3(D) and Chapter XXIII, 
Section 1(A) and (B) — approved by House of 
Delegates). 2. Amendment to Charter — Article 
VI and By-Laws Chapter XVII, Section 1 to add 
a member of the LAMPAC Board to the Ex- 
ecutive Committee of LSMS — not approved. 
3. Amendment to By-Laws — Chapter I, Section 
1(B) to provide dues-exempt membership for 
those regular members of the LSMS who have 
reached age 70 — approved. 4. Amendment to By- 
Laws — Chapter I, Section 2, first sentence, and 
Section 2(B) and Chapter VIII, Section 1(H) to 
provide for requirements for student membership 
— approved. 5. Amendment to By-Laws — Chap- 
ter III, Section 1(B) in re method of payment of 
dues — approved. 

Chronic Diseases: 1. The Committee continue 
its interest in the development of the Chronic 
Renal Disease Program under P.L. 92-603 — 
adopted. 2. Arrangements be made to obtain all 
information and guidelines prepared by the De- 
partment of Health, Education and Welfare, rela- 
tive to the CRD program and a copy of each 
piece of material be sent to each member of this 
Committee — adopted. 3. Arrangements be made 
by the State Society staff for a meeting of this 
Committee with the Regional Representative of 
Health, Education and Welfare and members of 
her staff — adopted. 4. The Committee respect- 
fully requests of the President of the Louisiana 
State Medical Society, if in his wisdom he con- 
siders it advisable, a practicing nephrologist ac- 
tively engaged in a dialysis program, be appointed 
to the Committee to add a needed point of view — 
adopted. 

Hall of Fame: 1. Nomination to the Hall of 
Fame of the Louisiana State Medical Society the 
following: Dr. Charles M. Horton; Dr, Walter 
Moss; Dr. Edwin L. Zander. 

Infectious Disease Control: 1. The Louisiana 
State Medical Society endorse the United States 
Public Health Service’s recommendation on rubel- 
la vaccine use in women of child-bearing age: 


June, 1974— Vol. 126, No. 6 


223 


ORGANIZATION SECTION 


viz. “It is desirable that programs of rubella 
vaccine use in non-immune adolescent girls and 
adult women be extended. Because of the precau- 
tions which must apply, potential vaccinees in 
this group should be considered individually. They 
should receive vaccine only if they agree to pre- 
vent pregnancy for two months after immuniza- 
tion.” 

This recommendation particularly applies to 
teachers, health professionals and others having 
close contact with large groups of children — 
adopted. 

2. Because of a significant incidence of nerve 
deafness and aseptic meningitis associated with 
natural infection by mumps virus, it is recom- 
mended that mumps vaccine be made available to 
patients utilizing public health clinics — adopted. 

3. The recommendation made by this Commit- 
tee in 1972 and approved in principle by the 
House of Delegates as follows is reaffirmed. 

“The Committee on Infectious Disease Control 
of the Louisiana State Medical Society endorses 
the administration of influenza vaccine for the 
chronically ill and the aged where feasible. Cur- 
rently, it specifically recommends that this vac- 
cine be made available to all indigent chronically 
ill and aged citizens in Louisiana.” — adopted. 

4. In view of recent reports in the medical 
literature regarding inadequate immunization 
against polio and measles secondary to improper 
vaccine storage and administration practices, we 
urge all physicians and other health professionals 
to observe the following precautions when han- 
dling polio and measles vaccines: 

a. Unopened OPV should be stored in the 
freezer — not in the refrigerator. 

b. Once opened, the liquid OPV must be used 
within a seven day period, during which time it 
must be stored at a temperature no higher than 
46° F (8° C). 

c. Before reconstitution, measles vaccine 
(alone or in combination with other vaccine vi- 
ruses) should be stored at 35.6° -46.4° F (2-8° C). 
Discard if not used within eight hours. 


d. Since temperatures of reconstituted vac- 
cines stored in the shelf of a refrigerator door 
have been reported in recent studies “to range 
from 36° -67° F on a typical working day” this 
site should preferably be avoided as a storage 
area for all live virus vaccines. Recommendation 
adopted. 

5. The Committee accepts the revisions to the 
pamphlet entitled Tetanus and Louisiana as 
amended and recommends its publication — adopt- 
ed. 

Insurance: 1. The LSMS Insurance Committee 
encourage component medical societies and med- 
ical staffs of hospitals to avail themselves of the 
Professional Liability Insurance Presentation 
prepared by the Division of Socio-Economics — 
adopted. 2. The LSMS Insurance Committee en- 
courage all LSMS members to participate in the 
various insurance programs developed by the 
LSMS — adopted. 

Journal: 1. Dr. John B. Bobear and Dr. A. V. 
Friedrichs be re-elected as members of the Com- 
mittee on Journal — referred to Committee on 
Nominations. 

Liaison with Medical Schools and SAMA : 
1. The Committee directed the Chairman to re- 
introduce a Resolution in the House of Delegates 
resolving that one student representative or his 
alternate, whether a SAMA representative or not, 
have full voting privileges in the House of Dele- 
gates — received and filed. 2. The Committee di- 
rected the Chairman to reintroduce a Resolution 
in the House of Delegates to effect a change in 
the Constitution and By-Laws that would permit 
the creation of a special classification of non- 
voting membership for medical students — received 
and filed. 

Liaison with Nurses: 1. The Louisiana State 
Medical Society approve and encourage the for- 
mation of councils of nurses within hospitals and 
regional councils — adopted. 2. Local medical so- 
cieties send MD representatives to meet with hos- 
pitals and regional councils of nurses — adopted. 

Liaison with Orgayiized Specialties: 1. It is 



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224 


J. Louisiana State M. Soc. 



ORGANIZATION SECTION 


recommended that prior projects and interests of 
the Committee be considered the objectives of the 
future year — adopted. 

Long Range Planning : 1. That the title of Ex- 
ecutive Vice-President be added to that of Secre- 
tary-Treasurer with no significant changes in 
duties. It was felt that by using the title of Ex- 
ecutive Vice-President, the Secretary-Treasurer’s 
remarks would receive more attention in the news 
media, when acting as an official spokesman of 
the Society — adopted. 

2a. That whenever possible LSMS Committee 
meetings be scheduled far in advance and meet- 
ing dates be published in the Journal. By doing 
this, any member knovTng of specific health 
problems who might be able to assist the various 
committees would have an opportunity to meet 
with them — adopted, b. The Committee also felt 
that consideration should be given to appointing 
committee members (when practical) from the 
same area in order to secure better attendance 
at committee meetings — deleted. 

3. That the Executive Committee and the 
Council on Legislation, through whatever mech- 
anism is necessary, secure legislation that would 
offer legal protection for more effective internal 
re^dew. It was suggested that information de- 
rived from internal review processes could be for- 
warded to the Louisiana State Board of Medical 
Examiners if warranted and if initial internal 
corrective measures had not resulted in solution 
of a particular problem. The Committee felt that 
revocation of membership, which amounts to 
moral suasion, is not sufficient punishment for 
physicians who violate medical ethics or perform 
their duties in an incompetent manner. It was 
also suggested that reports of hospital re^dew 
committees be sent to the LSMS Division of 
Socio-Economics for study and analysis. The 
Committee feels that the Louisiana State Medical 
Society should strengthen its surveillance of med- 
ical practice in Louisiana — after motion to delete 
second to last sentence was carried, motion to 
table was also voted upon and carried. 

4. To improve Medical Society-physician com- 
munications, it is recommended that: a) follow- 
ing each meeting of the Executive Committee, 
each Councilor send a “Councilor’s Report” to aU 
members in his district. The Councilor would be 
expected to write the report and the LSMS staff 
would be responsible for printing and distribu- 
tion. It was estimated that the cost of such a 
report would be $500 per issue — disapproved, 
b) The Committee also recommends that in addi- 
tion to publishing in the Journal synopsis of min- 
utes of the Executive Committee meetings and 
House of Delegates meetings, a brief narrative 
report on meetings covering their highlights be 
published in the Journal — approved, c) The Com- 
mittee also felt that internal conununications 


would be improved by extending an in\itation to 
all Parish Medical Society presidents to attend 
Executive Committee meetings as observers so 
that they would be in a better position to inform 
members of component societies about what the 
LSMS is doing — approved, d. It was also sug- 
gested that all members of the Executive Com- 
mittee take every opportunity (hospital staff 
meetings, etc.) to report on the actiwties of the 
Louisiana State Medical Society — approved. 

Louisiana Organizations for State Legislation: 

1. Committee continue to represent the Louisiana 
State Medical Society — adopted. 

Medical Aspects of Automotive Safety : 1. Phy- 
sicians in Louisiana be advised through CAP- 
SULES that the Committee on Medical As- 
pects of Automotive Safety pro^'ides the Louisi- 
ana Highway Safety Commission with an 18-man 
Medical Advisory Committee. This Committee 
prowdes assistance to the Conunission in cases 
of medically questionable vehicular drivers. These 
cases are automatically issued forms that must 
be completed by the family physician before be- 
ing rewewed by the Committee as to eligibility 
for the renewal of his driver’s license — adopted. 

2. Annual drivers license examination at age 
70 and over for renewal of drivers license — 
rejected. 

3. Mandatory seat belts in all vehicles — re- 
ferred back to Committee for rewording. 

4. Standard safety regulations for school 
buses — referred back to Committee for rewording. 

5. Strongly urge testing of motorcyclists prior 
to their being issued a permit to drive a motor- 
cycle — adopted. 

6. Training courses for motorcyclists on how 
to ride and become familiar with safety measures 
— adopted. 

7. Through the Louisiana Highway Safety 
Commission the Louisiana Legislature upgrade 
Louisiana safety laws to comply with national 
standards and regulations — adopted. 

8. Educational programs to acquaint physi- 
cians and the public on traffic safety measures — 
adopted. 

9. There be maintained at the State Medical 
Society headquarters a supply of pamphlets and 
reprints on safety which would be available to 
those interested in traffic safety — adopted. 

10. The Ci\dl Defense program be activated 
and brought up-to-date by contacting the area 
medical directors to find out if they are still 
interested in serving in that capacity. In those 
parishes without medical directors, contact or- 
ganized medical societies to name a medical di- 
rector for that parish. If no organized society 
exists, the Councilor for that District will assist 
in naming a medical director. The duties expect- 
ed of the medical directors wiU be outlined — 
deleted by Chairman of Committee. 


June, 1974 — Vol. 126, No. 6 


225 


ORGANIZATION SECTION 


Medical Education: 1. The Committee on Med- 
ical Education recognizes and recommends par- 
ticipation in available self-assessment programs 
— adopted. 

Medical Manpower : 1. Each physician in the 
State is urged to review the information present- 
ed in these studies and to offer comment in a 
constructive way so that the citizens of the State 
as a whole might continue to profit from increas- 
ing efficiency and effectiveness of medical edu- 
cation and physician distribution — adopted. 

Mental Health: 1. The LSMS endorse the idea 
of confidentiality and privileged communication 
for both psychiatrists and their patients where 
such communications are made for the purposes of 
diagnosis and treatment — withdrawn by Chairman 
of Committee. 2. The LSMS take appropriate 
action to assist the Louisiana Psychiatric Asso- 
ciation in introducing such legislation and in hav- 
ing it accepted by the Louisiana Legislature — 
withdrawn by Chairman of Committee. 

Pediatric and Adolescent Health: 1. The Pe- 
diatric Departments of the Medical Schools in the 
State be encouraged to expand the training of 
their house staffs^ to include adolescent health. 
It is particularly important because of youth rep- 
resenting the ever-increasing percentage of the 
population — rejected. 


WANTED 

MEDICAL DIRECTOR 

The Board of Trustees, Eleemosynary In- 
stitutions, is seeking physician applicants 
for a full-time position as medical director 
at each of the following state operated 
acute general hospitals: 

South Mississippi State Hospital, Laurel, 
Mississippi; Kuhn Memorial State Hospital, 
Vicksburg, Mississippi; Natchez Charity 
Hospital, Natchez, Mississippi. 

There would be no initial cost to the 
physician for equipment, office expenses, 
or secretarial expense. Estimated income, 
$50,000 annually. Physicians interested in 
these positions should contact the follow- 
ing board members: Joe M. Ross, M.D., 
The Street Clinic, Vicksburg: J. P. Tatum, 
M.D., 1314 19th Avenue, Meridian: Charles 
A. Hollingshead, M.D., 103 S. 12th Ave- 
nue, Laurel; John R. Young, M.D., 55 
Seargent Prentiss Drive, Natchez; O. B. 
Crocker, M. D., Bruce, or the Board's Of- 
fice, 1404 Woolfolk State Office Building, 
Jackson, Mississippi 39201. 


2. Reiterate the recommendation made on Feb- 
ruary 18, 1972, to the Executive Committee of the 
Louisiana State Medical Society, as follows: 

“This Committee encourages the establishment 
of out-patient ambulatory adolescent units in ap- 
propriate facilities throughout the State. (If this 
recommendation meets with the approval of the 
Executive Committee, it is suggested that it be 
forwarded to the State Department of Hospitals 
and other appropriate State agencies and private 
facilities.) ” — rejected. 

3. The House of Delegates recommend the 
establishment of an on-going Medical Advisory 
Committee to the Division of Health Maintenance 
and Ambulatory Patient Services of the Louisi- 
ana Health and Social and Rehabilitation Ser- 
vices Administration, concerning the EPSDT 
Program (Early and Periodic Screening Diag- 
nosis and Treatment) under Title XIX of the 
Social Security Act — adopted. 

4. The House of Delegates recommend the de- 
velopment in the State of Louisiana of regional- 
ization of Perinatal Intensive Care Units as ini- 
tially recommended by the House of Delegates of 
the American Medical Association. (AM A House 
of Delegates Clinical Convention, November 29- 
December 2, 1970. Resolution: 69 (C-70).) — 
adopted. 

5. The State Medical Society support the in- 
clusion of medical assessment as part of the 
evaluation process for special education children. 
Pursuant to Act 368 of the 1972 Regular Session 
of the Louisiana Legislature, the State Board of 
Education adopted rules and regulations for the 
evaluation of special children for placement in 
special education. The component parts of the 
special education centers and competent authority 
teams do not provide for medical assessment of 
the children being evaluated — adopted. 

6. The Louisiana State Medical Society be 
aware of the ever-increasing problem of drug 
abuse among the adolescent — adopted. 

Public Health: 1. Reaffirmation of previous 

recommendations and concurrence with a resolu- 
tion from the State Medical Society on the trans- 
fer of the present FHF program for family plan- 
ning in Louisiana to the Division of Health Main- 
tenance and Ambulatory Patient Services of 
LHSRSA— adopted. 

2. The Committee initiate a study of the pos- 
sible impact of the PSRO legislation on public 
health programs in the future — adopted. 

3. Encourage support for medical, public 
health and community emphasis in drug control 
programs, particularly for the young — adopted. 

4. Increased activities on the part of the of- 
ficial public health agencies at all levels, and in 
rural areas in particular, for improved programs 
for elimination of stream pollution and approved 


226 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


solid waste disposal, such as sanitary landfills, 
etc. — adopted. 

5. Increased emphasis by the public health 
agencies to improve the reporting of communica- 
ble diseases and to promote general epidemiology 
services — adopted. 

6. Support intensified VD control activities, 
with emphasis on case-finding and treatment of 
gonorrhea — adopted. 

7. Communicable disease education in public 
schools in Louisiana with special emphasis on 
venereal disease education — adopted. 

8. Increased activity in the Rubella immuniza- 
tion program for non-immunized females, with 
appropriate birth control measures for those at 
risk of pregnancy — adopted. 

9. Support the initiation and promotion of 
public health programs in the area of hyperten- 
sion — adopted. 

10. Promote mumps immunization in public 
health clinics — adopted. 

11. Continue to support and promote the pro- 
vision and administering of flu vaccine for indi- 
gents at high risk — adopted. 

12. The Committee study and come up with 
recommendations for some cooperative programs 
to deal with teenage pregnant girls, illegitimacy, 
and urgently seek real cooperation between the 
school systems, health departments, hospitals, 
social services, ministerial counseling and voca- 
tional rehabilitation — adopted. 

13. More involvement and cooperation with 
the area comprehensive health planning groups 
(“B” agencies) in establishing priorities; work 
closely with them in evaluating needs for health 
manpower, health facilities, environmental pro- 
grams and mental health programs — filed for 
information. 

Resolutions: 1. Copy of report be sent to each 
person and group mentioned — adopted. 2. Report 
to be published in the Journal of the Louisiana 
State Medical Society — adopted. 

Rural and Urban Health: 1. The Louisiana 
State Medical Society use its influence to urge 
the appropriate state health agency to publish a 
directory of all its institutions and agencies avail- 
able to indigent Louisiana residents and that a 
copy be mailed to all Louisiana physicians — 
adopted. 

Sports Medicine and College Health: 1. The 
Louisiana State Medical Society reiterate its in- 
tention to assist the State Board of Education 
in any way that it can — adopted. 2. Members of 
the University Health Program be included on 
this Committee since the change in the scope of 
the Committee from Sports Medicine to Sports 
Medicine and College Health — referred back to 
Committee for further study. 


Resolutions Adopted 
(Only “resolves” included) 

No. 700 — AM A Medicredit Bill (introduced by 
Jack R. Diamond, MD, Delegate) — RESOLVED, 
That LSMS reject the MEDICREDIT Bill of the 
AMA and instruct its delegates to oppose it. 

No. 704 — Survey regarding Ambulatory Health 
Care Service in Lafourche Parish (introduced 
by Lafourche Parish Medical Society) — RE- 
SOLVED, That Lafourche Parish Medical So- 
ciety offer no sanction for said proposed survey, 
and be it further 

RESOLVED, That the Louisiana State Medi- 
cal Society is requested to lend its support in 
instituting non-sanction of these proposed sur- 
veys, and be it further 

RESOLVED, That copy of this resolution be 
sent to Dr. Merlin Ohmer of Nicholls State Uni- 
versity. 

No. 705 — Opposition to National Health Policy 
and Health Development Act of 197 U (HR 12053) 
(introduced by the Executive Committee of the 
LSMS) — RESOLVED, That the Louisiana State 
Medical Society House of Delegates go on record 
as being opposed to HR 12053 as it presently 
stands and be it further 

RESOLVED, That copies of this Resolution be 
forwarded on to the Louisiana Congressional 
Delegation and be it further 

RESOLVED, That the Louisiana State Medi- 
cal Society Delegates to the AMA be instructed 
to introduce a similar Resolution to the AMA 
House of Delegates at the next AMA Annual 
Meeting. 

No. 707 — Non-Discovery Statutes of the Louisi- 
State Medical Society (introduced by Calcasieu 
Parish Medical Society — RESOLVED, That the 
Louisiana State Medical Society request that the 
Legislative Committee of this Society in coopera- 
tion with the attorneys of this organization pre- 
pare a Bill to be introduced in the Louisiana State 
Legislature by appropriate means eliminating as 
far as possible the activities and records of re- 
view committees from subpoena and discovery in 
malpractice and similar actions. 

No. 709 — To request the Congress of the United 
States to repeal Professional Standards Review, 
section 2A9F of Public Law 92-603 (introduced by 
Shreveport Medical Society) — RESOLVED, by 
the Louisiana State Medical Society in regular 
session May 5-7, 1974, in Lake Charles, Louisi- 
ana, that the Congress of the United States is 
hereby requested to repeal in its entirety Profes- 
sional Standards Review, section 249F of Public 
Law 92-603, immediately. 

No. 711 — To request the Governor of the State 
of Louisiana and the Louisiana Legislature not 
to amend the laws of Louisiana to license anyone 
to be a physician who is not a properly qualified 
Doctor of Medicine (introduced by Shreveport 


June, 1974— Vol. 126, No. 6 


227 


ORGANIZATION SECTION 


Medical Society) — RESOLVED, by the Louisiana 
State Medical Society in regular session May 5-7, 
1974, in Lake Charles, Louisiana, that in order 
to maintain the proper medical and health care 
standards for the people of Louisiana and in the 
interest of consumer protection and credibility, 
the Governor of the State of Louisiana and the 
Louisiana Legislature are hereby requested not 
to amend the laws of Louisiana to license anyone 
to be a physician who is not a properly qualified 
doctor of medicine as presently defined by the 
Medical Practices Act of Louisiana. 

No. 712 — Policy of the Louisiana State Medical 
Society concerning existing review procedures for 
Medicare, and payment of hospital and physician 
bills by the patient when Medicare does not make 
payment on these bills (introduced by Shreveport 
Medical Society) — RESOLVED, by the Louisiana 
State Medical Society in regular session May 5-7, 
1974, in Lake Charles, Louisiana, that the follow- 
ing policy be recommended: (1) The physician is 
to bill the Medicare patient directly for the health 
care services rendered. (2) The physician is not 
to accept assignments from Medicare for the 
health care services rendered. (3) The patient, 
therefore, is to be informed by the physician that 
the patient is responsible for his entire hospital 
bill and physician bill and may not be reimbursed, 
and such bills to be paid from private insurance 
and/or personal funds. 

No. 713 — To recommend that the Houses of 
Worship offer special prayers and services dur- 
ing October 13-20, 197 U, for all those working in 
the health professions (introduced by Shreveport 
Medical Society) — RESOLVED, by the Louisiana 
State Medical Society in regular session May 5-7, 
1974, in Lake Charles, Louisiana, that it is rec- 
ommended that the houses of worship offer spe- 
cial prayers and services during the week of 
October 13th to the 20th, 1974, for all those work- 
ing in the health professions who help relieve 
human suffering and work for the preservation 
of human life. 

No. 716 — Nurse Practice Act (introduced by 
East Baton Rouge Parish Medical Society) — RE- 
SOLVED, That the Louisiana State Medical So- 
ciety oppose any attempt to repeal the Nurse 
Practice Act, to eliminate the mandatory licen- 
sure examination, or any legislation which would 
lower the standards for Registered Nurses in 
Louisiana. 

No. 718 — Repeal of Anti-Substitution Drug 
Laws (introduced by East Baton Rouge Parish 
Medical Society) — RESOLVED, That the East 
Baton Rouge Parish Medical Society is against 
repeal of Anti- Substitution Drug Laws. 

No. 720 — Adjustment of professional medical 
fees following removal of Federal Controls (in- 
troduced by D. H. Johnson, Jr., MD, Delegate) — 
RESOLVED, That the House of Delegates of the 


Louisiana State Medical Society urges Society 
members to continue to exercise restraint in esca- 
lation of professional fees, adjusting them only to 
account for actual increased costs or to correct 
individual fee inequities when circumstances war- 
rant. 

No. 722 — Confidentiality of Hospital Medical 
Staff Committee Reports (introduced by D. H. 
Johnson, Jr., MD, Delegate) — RESOLVED, That 
the House of Delegates of the Louisiana State 
Medical Society advocates specific protection by 
statute of information obtained in any review 
mechanism intended to improve the quality of 
medical practice, and be it further 

RESOLVED, That the Council on Legislation 
of the Louisiana State Medical Society be in- 
structed to develop legislation to be submitted to 
the legislature of the State of Louisiana provid- 
ing confidentiality for material accumulated by 
physician committees representing Hospital Med- 
ical Staffs and/or organized medicine designed to 
improve the quality of medical practice through 
analysis of current or previous methods of prac- 
tice. 

No. 723 — Direct billing under National Health 
Insurance (introduced by D. H. Johnson, Jr., MD, 
Delegate) — RESOLVED, That the Louisiana 
State Medical Society is opposed to any provision 
in any National Health Insurance bill which 
would preclude direct billing of patients by phy- 
sicians, and be it further 

RESOLVED, That the Louisiana State Medi- 
cal Society instructs its Delegates to the House 
of Delegates of the American Medical Associa- 
tion to make this policy known and to seek to 
have it become the position of the American Med- 
ical Association in discussion of any National 
Health Insurance bill. 

No. 725 — Special Class of Non-Voting Mem- 
bership for Medical Students (introduced by J. 
W. Wilson, Jr., MD, Councilor of Fourth Dis- 
trict) — RESOLVED, That the Louisiana State 
Medical Society create a special class of non- 
voting membership for medical students attend- 
ing approved medical schools in Louisiana. Such 
membership would be through component so- 
cieties in areas where medical schools exist at 
the option of the component society with the com- 
ponent society specifying rights, privileges and 
responsibilities not to be in conflict with the Lou- 
isiana State Medical Society By-Laws. The Ex- 
ecutive Committee would specify the dues, and be 
it further 

RESOLVED, That appropriate changes be 
made in the By-Laws to permit this. 

No. 726 — To request the Congress of the United 
States to repeal Inchision of Chiropractor Ser- 
vices under Medicare section 273 of Public Law 
92-603 (introduced by Steve G. Kirkikis, MD, 
Delegate) — RESOLVED, by the Louisiana State 


228 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


Medical Society in regular session in Lake 
Charles, Louisiana, May 5-7, 1974, that in order 
to maintain the proper medical and health care 
standards for the American people and in the 
interest of consumer protection and credibility, 
the Congress of the United States is hereby re- 
quested to repeal in its entirety Inclusion of 
Chiropractor Services under Medicare, section 
273 and chiropractors’ services under Medicaid, 
section 275, of Public Law 92-603. 

No. 727 — PSRO (introduced by the Ascension 
Parish Medical Society) — RESOLVED, That the 
Louisiana State Medical Society House of Dele- 
gates terminate further study of PSRO which 
contemplates a possible change in the repeal pol- 
icy of the Society, and be it further 

RESOLVED, That the Louisiana State Medical 
Society strongly urges that hospital medical 
staffs not participate in any manner in PSRO. 

No. 732 — Commendation for Dr. Charles Mary 
(introduced by Executive Committee of LSMS) — 
RESOLVED, That the Louisiana State Medical 
Society commend Dr. Charles C. Mary for his 
perseverence in the face of adversity and for his 
personal sacrifices in the search for truth. 

Special Resolution No. 1 — Commendation for 
Mr. Percy J. Landry, Jr. (introduced by Past 
Presidents Advisory Council) — RESOLVED, 
That the Louisiana State Medical Society ex- 
press its appreciation to Mr. Percy J. Landry, 
Jr. for a job well done for 19 years, in the highest 
tradition of the legal profession, and be it further 

RESOLVED, That the Louisiana State Medical 
Society extend every good wish to Mr. Percy J. 
Landry, Jr. for continued success in his personal 
and professional endeavors and be it further 

RESOLVED, That copies of this resolution be 
transmitted to Mr. Percy J. Landry, Jr.; Honor- 
able James J. Fitzmorris, Lt. Governor of the 
State of Louisiana; Honorable Bubba Henry, 
Speaker of the House of Representatives, State 
of Louisiana, and to the President of the Louisi- 
ana State Bar Association. 

Special Resolution No. 3 — Support of President 
Nixon (introduced by Richard L. Buck, MD, Dele- 
gate) — RESOLVED, That the Louisiana State 
Medical Society go on record to the Representa- 
tives and Senators that they want no part of his 
resignation or impeachment. 

Other Resolutions 

No. 701 — Past Presidents’ Report to the House 
of Delegates (introduced by A. L. Cook, MD and 
B. J. Guilbeau, MD, Delegates) — tabled. 

No. 702 — Election of Councilors to the Louisi- 
ana State Medical Society (introduced by A. L. 
Cook, MD and B. J. Guilbeau, MD, Delegates) — 
disapproved. 

No. 703 — Amendment to By-Laws, Chapter 
XII, Section 5, Rights (introduced by The Board 


of Governors of the Orleans Parish Medical So- 
ciety) — tabled. 

No. 706 — Rights of Physicians on Medical 
Staffs and Responsibilities of Physicians on Med- 
ical Staffs (introduced by Calcasieu Parish Med- 
ical Society) — tabled. 

No. 708 — Physician Membership on Hospital 
Boards (introduced by Calcasieu Parish Medical 
Society) — tabled. 

No. 710 — To request the Governor of the State 
of Louisiana to provide adequate fuel and gaso- 
line to the physicians and allied medical person- 
nel of Louisiana (introduced by Shreveport Med- 
ical Society) — tabled. 

No. 714 — To request the Congress of the United 
States and the Cost of Living Council to remove 
and suspend the economic controls on medical 
care (introduced by Shreveport Medical Society) 
— tabled. 

No. 715 — The Enrichment of Rice and Grits 
(introduced by the East Baton Rouge Parish 
Medical Society) — tabled. 

No. 717 — Solicitation of Patients (introduced 
by East Baton Rouge Parish Medical Society) — 
withdrawn. 

No. 719 — PSRO (introduced by East Baton 
Rouge Parish Medical Society) — withdrawn in 
lieu of Res. No. 727. 

No. 721 — Retrospective Audit Committee con- 
cept (introduced by D. H. Johnson, Jr., MD, Dele- 
gate) — tabled. 

No. 724 — Voting Privileges for Medical Student 
Delegates (introduced by J. W. Wilson, Jr., MD, 
Councilor of Fourth District) — rejected. 

No. 728 — Rejection of Joint Commission on Ac- 
creditation of Hospitals Audit Requirement (in- 
troduced by the Lafourche Parish Medical So- 
ciety) — tabled for legal discussion (was not re- 
moved from table). 

No. 729 — TAP (Trustees, Administrators, Phy- 
sicians) requirement by JCAH (Joint Commis- 
sion on Accreditation of Hospitals) (introduced 
by the Lafourche Parish Medical Society) — ^with- 
drawn. 

No. 730 — Endorsement of Candidate for AMA 
Board of Trustees (introduced by Terrebonne 
Parish Medical Society) — tabled. 

No. 731 — Appropriation of $70,000 to refute 
defamatory attacks upon profession through the 
News Media (introduced by Wesley N. Segre, 
MD, Delegate) — rejected. 

Special Resolution No. 2 — Recommendations 
for Legislative Action May, 1974 (introduced by 
Jefferson Parish Medical Society) — referred to 
Council on Legislation, with approval. 

Special Resolution No. 4 — Extension of an in- 
vitation to a committee of the American Associa- 
tion of Medical Assistants, Louisiana Chapter, to 
appear before the House of Delegates of the Lou- 
isiana State Medical Society (introduced by Rich- 


JUNE, 1974 — VOL. 126, No. 6 


229 


ORGANIZATION SECTION 


ard L. Buck, MD, Delegate) — in lieu of resolu- 
tion invite Louisiana Chapter of AAMA to have 
a display at the next Annual Meeting; also ex- 
press thanks for those who have assisted at regis- 
tration desks during the 1974 Annual Meeting. 

Other Action Taken 

Acceptance of resignation from Mr. Percy J. 
Landry, Jr., Legislative Consultant (see special 
resolution No. 4). 

Commendation of Dr. Gerald Weiss in re activ- 
ity in connection with Constitutional Convention. 

House of Delegates to continue opposition to 
chiropractic. 

Legislative Council instructed to put as many 
restrictions as possible on chiropractic legislation 
if passed. Authorized to introduce substitute bill 
if necessary. 

Disapproval of delay in ballot vote for officers 
for arrival of one delegate. 

Invitation to hold 1978 meeting in New Orleans 
accepted. 

Other Matters Discussed 

Cost controls. 

Possibility of shortening sessions of House of 
Delegates. 

Tentative invitation to hold meeting in Thiho- 
daux. 

Assessment of members for legislative and po- 
litical activities. 

Election of Officers, AMA Delegates 
AMA Alternate Delegates and Committees 

F. Michael Smith, Jr., MD, President-Elect 

Thomas Y. Gladney, MD, First Vice-President 

Arthur G. Kleinschmidt, Jr., MD, Second Vice- 
President 

Stephen E. Carter, MD, Third Vice-President 

Maurice E. St. Martin, MD, Chairman, House 
of Delegates 

Eugene F. Worthen, MD, Vice-Chairman, 
House of Delegates 

Lawrence D. Kavanagh, MD, Councilor, First 
District 

John Tanner, MD, Councilor, Second District 

Sam L. Gill, MD, Councilor, Fourth District 

Stanley R. Mintz, MD, Councilor, Fifth District 

W. Charles Miller, MD, AMA Delegate 

Gordon W. Peek, MD, AMA Delegate 

Eugene C. St. Martin, MD, AMA Alternate 
Delegate 

Frank A. Riddick, Jr., MD, AMA Alternate 
Delegate 

John B. Bobear, MD, Member, Committee on 
Journal 


A. V. Friedrichs, MD, Member, Committee on 
Journal 

Gordon W. Peek, MD, Member, Committee on 
Medical Defense 

Elmo J. Laborde, MD, Member, Council on 
Legislation 

Future Annual Meetings 

1975 — New Orleans 

1976 — Shreveport 

1977 — Baton Rouge 

1978 — New Orleans 


LOUISIANA STATE MEDICAL SOCIETY 
REPORT OF COMMITTEE ON RESOLUTIONS* 

1974 Annual Meeting — Lake Charles 
May 5-7 

The Louisiana State Medical Society has just 
completed one of the most enjoyable and in- 
structive Annual Meetings in the history of the 
Society and there are many individuals and or- 
ganizations that have contributed to the success 
of this meeting. 

We must first express thanks to the entire 
Calcasieu Parish Medical Society and the Wom- 
an’s Auxiliary of this component society who 
have worked diligently in making such excellent 
arrangements under the Co-Chairmanship of Drs. 
Walter Moss and J. Y. Garber. 

Lake Charles has one of the finest Civic Cen- 
ters in the world and the Manager, Mr. Alfred 
LeBlanc, the Assistant Manager, Mr. W. Rozas 
and the entire staff of employees have spared 
nothing in striving to make their excellent fa- 
cilities adaptable for this convention. 

The local chapter of the Louisiana Medical 
Assistants rendered most valuable services at the 
registration desks during the meeting and we 
wish to extend to them our sincerest thanks. 

The House of Delegates was honored to have 
the President-elect of the American Medical As- 
sociation, Dr. Malcolm C. Todd, present and his 
address before the luncheon was indeed enlight- 
ening. 

Hon. Russell Long met with members for dis- 
cussion of PSRO and was very helpful in this 
conference. 

Hon. David C. Treen was the featured speaker 
at the LAMPAC luncheon and his presence was 
conducive to a large and interested attendance. 

Msgr. Irving A. DeBlanc inspired those pres- 
ent at the breakfast sponsored by the Committee 
on Medicine and Religion and those who were 
unfortunate enough to miss his talk were denied 
a helpful devotional message. 

The following participants in the scientific 
program are to be commended for their excellent 


* Adopted by House of Delegates, May 7, 1974. 


230 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


presentations: Messrs. Perry Plexico, Kenneth 
Kempner and Allan Demmerle, who presented a 
panel on “Telemetry and Computer Applications 
in Medicine.” Lt. Col. Gerald Carr, Astronaut of 
Skylab 4 Mission, told of the “Effects of Space 
Travel on Humans” which was a most fascinating 
talk for members as well as guests. Although one 
of the panelists for presentation of the subject of 
“Use and Abuse of Antibiotics,” Dr. William J. 
Holloway, was unable to be present due to illness 
of his wife, the subject was very ably handled 
by Dr. William B. Deal. Our attorney, Mr. Henry 

B. Alsobrook and a member of the Society, Dr. 
D. H. Johnson, Jr., held an interesting discussion 
on the subject of “How to Act in Court”. 

The LSU Medical Television programs handled 
by the LSU Continuing Medical Education De- 
partment and the Louisiana Hospital Television 
Network were again an outstanding feature of 
the Annual Meeting. Thanks are particularly 
extended to Dr. William H. Stewart, Commis- 
sioner of the Health and Social and Rehabilita- 
tion Services Administration and to Dr. Rafael 

C. Sanchez and others from the LSU School of 
Medicine for making these programs available. 

Thanks are expressed to Channel 7 in Lake 
Charles for coverage of the meeting and to Ms. 
Corinne Pearce of the Lake Charles American 


Press and Ms. Kathleen Malloy of the Beaumont 
Enterprise for excellent newspaper articles. 

The Sheraton Chateau Charles, the Down- 
towner and other motels in the area offered ex- 
cellent facilities for doctors and others attending 
the meeting and all courtesies extended were in- 
deed appreciated. 

An unusual number of scientific exhibits were 
presented and the arrangements for viewing 
these exhibits were most satisfactory. 

Social activities were outstanding. The Bon 
Ton Roulee Party was most unusual and a de- 
lightful experience for members and guests. Mr. 

D. R. Siebarth (Jean Lafitte) of the Buccaneers 
and all of his crew offered a most enjoyable 
program for the evening. 

The elaborate swamp arrangements prepared 
by the Woman’s Auxiliary for the dinner dance 
and other props showed unusual talent and ef- 
forts of these members of the Auxiliary in this 
regard are deeply appreciated. 

The ladies also hosted a cocktail party for 
early arrivals on Saturday evening. 

The Past Presidents rendered a most valuable 
report to the House of Delegates. This was pre- 
pared at a meeting held at the Pioneer Club and 
thanks are extended to the management of the 
Club for excellent arrangements for this function 


Keogh and You 


Who is eligible? 

B Every self-employed person engaged in business 
for himself or as a partner in a partnership. 

(Generally, a person who is subject to the Self- 
Employment Tax relating to Social Security.) 

Determining earned income 

* Earned income includes all of the net earnings 
from trade or business even if both personal ser- 
vices and capital are material income-producing 
factors, provided the taxpayer devotes most of 
his time to the business. 


Federal Income Tax deductions 

(whether or not an Owner-Employee) 

* 100% of all contributions, including those for 

employees, subject to a maximum deduction of 
$2,500 for self-employed person's contributions 
on his own behalf. 

Maximum annual contribution tor 
Owner-Employees 

■ 10% of earned income or $2,500, whichever is 
less. Fixed percentage applicable each year Is 
specified in executed pension plan document. 


The Keogh plan will have the following effect on 
your Federal Income Tax: 


Without With 

Plan Plan 

$52,000 Net Earned Income $51,500 

0 Personal Retirement Plan Deduction 2,500 

52.000 Adjusted Gross Income 49,000 

9,000 Deductions and Exemptions 9,000 

43.000 Net Taxable Income 40,000 

$13,580 Federal Income Tax $12,140 



Where the future is now 


r 


Metropolitan Life 

Bob Stevens Jacques L Couret 

Sales Representative Sales Representative 
3621 Veterans Boulevard 

Office: 888-3371 Metairie, La. 70002 

Name: 

Address: 

City: 


S state: Zip: 


Telephone: 


June, 1974 — Vol. 126, No. 6 


231 


ORGANIZATION SECTION 


as well as for the dinner held for the wives of 
the past presidents on the same night. 

The Rapides Parish Medical Society hosted a 
cocktail party for president-elect H. H. Hardy, 
Jr., preceding the dinner dance on Monday eve- 
ning and it was a privilege to honor the new 
president in this manner. 

The A. H. Robins Company again presented 
a plaque for outstanding community service and 
we congratulate Dr. Adam John Tassin, Jr., who 
was selected recipient of this award. 

Congratulations are in order for the following 
doctors who were recognized for fifty years of 
medical practice: Drs. George B. Briel, Donovan 
C. Browne, Earl Z. Browne, Maurice Campagna, 
Ulysses S. Hargrove, William K. Irwin, Daniel R. 
McIntyre, Nathan H. Polmer, Warren L. Rosen, 
George L. Smith, J. Kelly Stone, Willard R. 
Wirth and Charles S. Wood. 

The Secretary of the Louisiana State Board of 
Medical Examiners presented a report to the 
House of Delegates and he is to be commended 
for the excellent service rendered by him and the 
entire Board in the interest of Medicine in this 
State. 

The Pan-American Life Insurance Company 
was most hospitable in hosting a hospitality 
period for members on Monday evening. 


Dr. James H. Stewart, President for 1973-74 
extended his services to the Society during this 
meeting and the members are indebted to him for 
his excellent handling of affairs for the organi- 
zation during his term of office. 

The new Chairman of the House of Delegates, 
Dr. Maurice E. St. Martin, handled the business 
of the House most expeditiously and when the 
gavel was turned over to the new Vice-Chairman, 
Dr. Eugene F. Worthen, the agenda was handled 
in the same expert manner. 

No Annual Meeting can be arranged without 
the assistance of the entire staff of the State So- 
ciety and Dr. Ashton Thomas and all of his co- 
workers are indeed commended for their tradi- 
tional efficiency and interest in all matters which 
pertain to operation of the organization. 

Recommendations 

1. Copy of report be sent to each person and 
group mentioned. 

2. Report to be published in the Journal of 
the State Society. 

Respectfully submitted: Avery L. Cook, MD, 
Member; Elmo J. Laborde, MD, Member; J. Y. 
Garber, MD, Chairman. 


232 


J. Louisiana State M. Soc. 


mjtcj 



CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every month 


Calcasieu 

Fourth Tuesday of every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday of every month 

Baton Rouge 

Jackson- Lincoln- Union 

Third Tuesday of every month 
except summer months 

Jeflerson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every other month 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

1 ndependence 

Terrebonne 

Third Monday of every month 

Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday of every month 



AMA/AAMA ACCREDITATION GIVEN 
GOVERNMENTAL RECOGNITION 

The Council on Medical Education of the 
American Medical Association, in collaboration 
with the American Association of Medical Assis- 
tants, has been recognized by the U. S. Commis- 
sioner of Education as an official agency to 
accredit educational programs for the medical 
assistant. 

Mrs. Marian G. Cooper, CMA, president of 
AAMA, and Mrs. Elvera Fischer, RN, CMA, 
chairman of the Curriculum Review Board, ex- 
pressed gratification at the decision, which ap- 
plies to programs in both public and private in- 
stitutions. 

AMA and AAMA have collaborated on the ac- 
creditation of medical assisting programs since 
July 1969, when curriculum standards were ap- 
proved by the AMA House of Delegates. To date 
58 one- and two-year programs have been ap- 
proved in junior and community colleges and 
proprietary schools. 


THE LOUISIANA CAMP FOR DIABETIC 
CHILDREN 

YMCA Camp Singing Waters 

Two weeks of the YMCA Camping Season are 
set aside for youngsters with diabetes mellitus 
so that they may enjoy the fun of summer camp- 
ing. In addition to the regular YMCA staff, this 
session is supervised by physicians, nurses, dieti- 
tians and laboratory technicians with a special 
interest in diabetes. The primary goal of this ses- 


sion is to provide the diabetic child with a camp- 
ing experience under medical supervision. Activi- 
ties are planned so that the possibilities of insulin 
reactions are greatly minimized. Canoeing, horse- 
back riding, archery, crafts, riflery, fishing and 
many other fun-filled activities are available. 

Camp will begin on Sunday, July 21, 1974 and 
close on Saturday, August 4, 1974. 

Camp Singing Waters is located in Livingston 
Parish at Holden, Louisiana. The camp is 30 miles 
east of Baton Rouge and 12 miles west of Ham- 
mond on Highway 190. The 75-acre site includes 
a lake and lagoons and is located next to the 
Tickfaw River. 

The camp is a non-profit operation. Many of 
the services provided are voluntary. Many of the 
supplies are donated. The actual cost of the two- 
week camping period amounts to $185.00 per 
child. A registration fee (non-refundable) of 
$25.00 must accompany the application and will 
be credited toward the camp fee. Assistance will 
be offered to those parents who are unable to 
pay the camp fees. Children aged 8-14 are 
eligible to apply. 

For application forms and further information, 
please call or write the Diabetes Association of 
Greater New Orleans, 606 Common St., New Or- 
leans, Louisiana 70130. (504) 524-H-E-L-P. 


SEPTEMBER AND OCTOBER 1973 LSMS 
JOURNALS NEEDED 

The LSMS has exhausted its supply of the Sep- 
tember and October 1973 issues of The Journal 


June, 1974 — Vol. 126, No. 6 


233 


MEDICAL NEWS 


of the Louisiana State Medical Society. Members 
who have copies of these issues, and no longer 
have need for them, are urged to return them to 
the Journal office. 


20th ANNUAL SOUTHERN OB-GYN 
SEMINAR 
JULY 21-26, 1974 

The 20th Annual Ob-Gyn Seminar will be held 
again this year in Asheville, North Carolina at the 
Grove Park Inn, July 21 through July 26. 

A wide variety of subjects in obstetrics and 
gynecology will be presented and program par- 
ticipation will include the medical schools of 
North Carolina, Duke, Bowman Gray and the 
Medical College of Virginia, in addition to out- 
standing speakers from other areas. 

For registration information, please contact 
the Secretary, Dr. George T. Schneider, 1514 
Jefferson Highway, New Orleans, Louisiana 
70121. 


ODYSSEY HOUSE OPENS LOUISIANA 
BRANCH 

Odyssey House of Louisiana has been opened 
at 1125 North Tonti Street, New Orleans for the 
treatment and rehabilitation of drug addicts. It 
is 1 of 33 treatment facilities in the following 
states: Michigan, New Hampshire, New Jersey, 
New York, and Utah. 

The philosophy underlying the program is that 
drug addiction is a symptom of a self-destructive 
psychologic disorder. Therefore, to cure the 
addict, his personality must be restructured so 
that conventional personal growth replaces drug 
dependency. This is best done in an in-residence 
therapeutic community wherein no substitute 
drugs are used ; absence of drug use is assured by 
witnessed urine screening three times a week; 
and there is continuing supervised open-group 
confrontation among residents that forces them 
to face the reality of themselves, their peers and 
their environment. 

Duration of treatment is 18 months under the 
supervision of a staff which is 50% professional 
and 50% trained ex-addict graduates. 

Odyssey House claims that 98% of its grad- 
uates remain drug-free and points to their 
$12,000 average yearly income as evidence of 
their total rehabilitation; they further state that 
85% of those who leave the program against 
medical advice after only 6 months of treatment 
remain drug-free. 

There is no charge for the treatment; prac- 
tically all support is generated from outside 
sources. 

No one is refused induction — there is always 
room for one more. 

For further information about the program 


telephone (504) 821-9211; ask for Mrs. Mar- 
gared Pike, RN, or Frank Lemons. 


COURSE ON DISEASES OF THE LIVER 

A course on Diseases of the Liver will be 
given at the Hotel Fontainebleau, November 21- 
23, 1974, under the direction of Leon Schiff, MD, 
Department of Medicine, University of Miami. 
The course will comprise the diagnostic approach 
to liver disease and jaundice including the clin- 
ical examination, laboratory tests, hepatic scinti- 
scan, needle biopsy, laparoscopy, roles of the 
radiologist and surgeon. A discussion of acute 
and chronic liver disease will include viral, drug 
induced and alcoholic hepatitis, Reye’s syndrome, 
chronic active liver disease, the Budd-Chiari syn- 
drome and primary biliary cirrhosis. Considera- 
tion will be given to malignant tumors, amebic 
abscess of the liver, origin and treatment of 
ascites, hepatorenal syndrome, surgical ap- 
proaches to portal hypertension and hepatic 
coma. Panel discussions will conclude each ses- 
sion. 

Tuition is $150; Physicians in Training $75; 
Nurses $50. 

Address inquiries to: Leon Schiff, MD, Pro- 
fessor of Medicine, University of Miami School 
of Medicine, P. O. Box 520875 Biscayne Annex, 
Miami, Florida 33152. 



CITIES SERVICE 
COMPANY 


•MEDICAL DIRECTOR 

Diversified natural resources company 
headquartered in Tulsa, seeking qualified 
full-time Medical Director, Position includes 
medical department administration and 
medical services in the corporate head- 
quarters in Tulsa, as well as supervisory 
administration of medical services in several 
domestic locations in the U S. Background 
in industrial and internal medicine is desir- 
able but not essential. Extensive company 
benefit plans included. 

Please telephone inquiries or send resume to: 

P. M. Davis 

Cities Service Company 
P.O. Box 300 
Tulsa, OK 74102 

Telephone: (918) 586-2476 


An Equal Opportunity Employer M/F 



234 


J. Louisiana State M. Soc. 





euiewS 


Principles of Clinical Electrocardiography, by 

M. J. Goldman. Ed 8, Lange Medical Publica- 
tions, Los Altos, 1973, $8.00. 

This is a clear, concise and well-illustrated in- 
troduction to clinical electrocardiography. The 
popularity of this text is evidenced by the fact 
that this is its 8th edition since the first one 
published in 1956. Moreover, the price is well 
within the reach of students and house officers. 
Thus, this text needs no reviewer to extoll its 
virtues. However, I would offer a few sug- 
gestions and criticisms. For example, a discus- 
sion of ventricular hypertrophy in infants and 
children would be helpful to the reader. A dis- 
cussion of the concept of idioventricular tachy- 
cardia should be included in the chapter on ven- 
tricular arrhythmias. Also, a list of electrocardio- 
graphic changes which constitute definite evi- 
dence of myocardial disease and those changes of 
lesser importance, would be a welcome addition 
to the appendix. 

Finally, I believe the chapter on “An Introduc- 
tion to Spatial Vectorcardiography” is somewhat 
misleading for the novice. The assumption that 
the “corrected” lead systems are “more correct” 
than some of the more classic lead systems, eg, 
the equilateral tetrahedron, is not true, either 
from a theoretical or, in particular, a practical 
point of view. The perpetuation of this assump- 
tion is undoubtedly one of the reasons that vector- 
cardiography has lagged behind in its contribu- 
tion to clinical medicine. 

T. Giles, MD 


Hereditary Retinal and Choroidal Disease-, by 
Alex E. Krill. Volume I: Evaluation, Harper 
& Row, Publishers, Hagerstown, Md., 1972, 
354 p, $19.75. 

At about the time this book was received, word 
came to us of the tragic death of the primary 
author in an airline crash in Chicago. This beau- 
tifully written volume therefore serves as a final 
monument to his talents. 

Although primarily for ophthalmologists, there 
is much in this book to interest the physician in 
other fields. This is particularly true of the chap- 
ter on “Principles of Genetics”. The chapter is 
so well organized and the material so well pre- 
sented that one needs practically no background 
in this field to begin to understand this relatively 
complex subject. Since almost all chromosomal 
aberrations are characterized by ocular abnor- 
malities, there is a surprising element of com- 
pleteness to the chapter. Two interesting and most 
practical aspects of the subject, pharmacogenetics 
and the therapy of inborn errors, are briefly dis- 
cussed. It is encouraging to be reminded that 
many of our patients, although born with genetic 


abnormalities, can be helped by one or another of 
the several approaches noted. 

The second, and by far the largest chapter in 
this volume, was written by Desmond B. Archer, 
one of Dr. KrilTs “superb” retinal fellows. While 
fluorescein angiography is primarily of interest to 
ophthalmologists, there is much to be learned by 
this technique by everyone with an interest in the 
anatomy and pathology of small blood vessels. 
The section is profusely illustrated with angio- 
grams of many conditions involving or affecting 
the retinal vasculature system. 

The balance of the book deals with somewhat 
specialized ophthalmologic diagnostic entities, too 
long relegated to the sophisticated laboratory. 
The average ophthalmologist, virtually untrained 
in the interpretation of electroretinograms, elec- 
troculograms, etc., would do well to become more 
familiar with the wealth of information available 
to him through such studies. I have seen no book 
more suitable for such a “postgraduate course” 
in electrophysiology. The evaluation of night vi- 
sion, dark adaptation, and color vision are thor- 
oughly covered in other chapters. 

In the preface there is reference to an addition- 
al volume or volumes. We all hope that the loss 
of this most gifted scientist and ophthalmologist 
will not result in curtailment of the series. 

N. W. PiNSCHMIDT, MD 


Symposium: Anorexia Nervosa and Obesity-, edit- 
ed by R. R. Robertson. Royal College of Physi- 
cians of Edinburgh, 1973, £2.00. 

This brief volume contains the proceedings at 
the symposium on anorexia nervosa and obesity 
held by the Royal College of Physicians at Edin- 
burgh in 1972. 

It presents a succinct, interdisciplinary over- 
view of these two perplexing and, at least in 
terms of clinical management, difficult syn- 
dromes. 

Anorexia nervosa, which is far more prevalent 
than the average clinician realizes, remains a 
very poorly understood entity which has been the 
subject of a great deal of metapsychological spec- 
ulation in the psychiatric literature. The Edin- 
burgh Symposium avoided any excursions into 
such speculation. The papers address themselves 
in a very practical fashion to the definition and 
clinical course of anorexia nervosa and to the 
physiological and endocrine parameters of that 
condition as well as social and psychological fac- 
tors pertaining to it. The paper by Dr. G. F. M. 
Russell on the nursing management of this con- 
dition is probably the most lucid and clinically 
useful practicum on the subject that this reviewer 
has ever read. 


June, 1974— Vol. 126, No. 6 


235 


BOOK REVIEWS 


In view of the very enthusiastic claims made 
by clinicians utilizing behavioral modification 
techniques resulting in the “cure” of anorexia 
nervosa, it is instructive to take heed of Dr. Rus- 
sell’s cautionary note that the ultimate result of 
long-term versus short-term therapy modalities 
must be carefully distinguished since this is basi- 
cally a chronic disease manifested by spontaneous 
remissions and exacerbations over a course of 
many years. 

The six papers on obesity address various 
aspects of this very large problem. These chap- 
ters dealing with etiological factors, management, 
psychiatric aspects, and the relationship of obe- 
sity to clinical diabetes are succinct, instructive 
and clinically useful. The authors stressed the 
observation that obesity is a complex disorder 
and rather than being a single clinical entity is 
a group of conditions with multiple etiology and 
differing characteristics. Given the genetic, en- 
vironmental, psychological and physiological fac- 
tors in operation, management must be carefully 
tailored to the individual case following a care- 
ful assessment from both a biological and psy- 
chiatric viewpoint. Although results of treatment 
are notoriously inconstant, the physician with a 
sound knowledge of the problem of obesity and a 
large measure of perseverance can help instruct 
and treat patients according to a rational reg- 
imen which is most likely to produce gratifying 
and relatively permanent results. 

Wallace K. Tomlinson, MD 


PUBLICATIONS RECEIVED 

( Certain ones of these will be selected for review. ) 

Doubleday & Co., Inc., N. Y. : The Uncertain 
Miracle, by Vance H. Trimble; What to Do 
About Your Brain-Injured Child, by Glenn Do- 
man; The Malnourished Mind, by Elie Shneour; 
Arthritis, by Sheldon Paul Blau, MD and Dodi 
Schultz; The Ethics of Genetic Control Ending 
Reproductive Roulette, by Joseph Fletcher; The 
Ultimate Stranger: The Austistic Child, by Dr. 
Carl H. Delacato. 

Lange Medical Publications, Los Altos, Calif.: 
Handbook of Surgery, by John L. Wilson, MD 
(5th ed.) ; Current Medical Diagnosis & Treat- 
ment 1974, by Marcus A. Krupp, MD and Mil- 
ton J. Chatton, MD ; Current Pediatric Diagnosis 
& Treatment, by C. Henry Kempe, MD, Henry 
K. Silver, MD, and Donough O’Brien, MD; Hand- 
book of Poisoning, by Robert H. Dreisbach, MD 
(8th ed.). 

The C. V. Mosby Co., St. Louis: Treatment of 
Cardiac Emergencies, by Emanuel Goldberger, 
MD; Immediate Care of the Acutely III and In- 
jured, edited by Hugh E. Stephenson, Jr., MD. 

Royal College of Physicians of Edinburgh: 

Symposium on Preventive Medicine. 


Rondomycin 

(methacycline HCI) 


CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines. 

WARNINGS: Tetracycline usage during tooth development (last half of pregnancy to eight 
years) may cause permanent tooth discoloration (yellow-gray-brown), which is more 
common during long-term use but has occurred after repeated short-term courses. 
Enamel hypoplasia has also been reported. Tetracyclines should not be used in this age 
group uniess other drugs are not likely to be effective or are contraindicated. 
Usage in pregnancy. (See above WARNINGS about use during tooth development.) 

Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de- 
veloping fetus (often related to retardation of skeletal development). Embryotoxicity has 
also been noted in animals treated early in pregnancy. 

Usage in newborns, infants, and children. (See above WARNINGS about use during 
tooth development.) 

All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease 
in fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6 
hours was reversible when drug was discontinued. 

Tetracyclines are present in milk of lactating women taking tetracyclines. 

To avoid excess systemic accumulation and liver toxicity in patients with impaired renal 
function, reduce usual total dosage and, if therapy is prolonged, consider serum level de- 
terminations of drug. The anti-anabolic action of tetracyclines may increase BUN. While 
not a problem in normal renal function, in patients with significantly impaired function, 
higher tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis. 

Photosensitivity manifested by exaggerated sunburn reaction has occurred with tetra- 
cyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be so ad- 
vised, and treatment should be discontinued at first evidence of skin erythema. 
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible organisms, 
including fungi, discontinue antibiotic and.start appropriate therapy. 

In venereal disease, when coexistent syphilis is suspected, perform darkfield exami- 
nation before therapy, and serologically test for syphilis monthly for at least four months. 

Tetracyclines have been shown to depress plasma prothrombin activity; patients on an- 
ticoagulant therapy may require downward adjustment of their anticoagulant dosage. 

In long-term therapy, perform periodic organ system evaluations (including blood, 
renal, hepatic). 

Treat all Group A beta-hemolytic streptococcal infections for at least 10 days. 

Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, avoid 
giving tetracycline with penicillin. 

ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms): anorexia, nausea, 
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with monil- 
ial overgrowth) in the anogenital region. 

Skin: maculopapular and erythematous rashes; exfoliative dermatitis (uncommon). Pho- 
tosensitivity is discussed above (See WARNINGS). 

Renal toxicity; rise in BUN, apparently dose related (See WARNINGS) . 

Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura, 
pericarditis, exacerbation of systemic lupus erythematosus. 

Bulging fontanels, reported in young infants after full therapeutic dosage, have disap- 
peared rapidly when drug was discontinued. 

Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia. 

Over prolonged periods, tetracyclines have been reported to produce brown- black mi- 
croscopic discoloration of thyroid glands; no abnormalities of thyroid function studies are 
known to occur. 

USUAL DOSAGE: Adulls-600 mg daily, divided into two or four equally spaced doses. 
More severe infections: an initial dose of 300 mg followed by 150 mg every six hours or 
300 mg every 12 hours. Gonorrhea; In uncomplicated gonorrhea, when penicillin is con- 
traindicated, 'Rondomycin' (methacycline HCI) may be used for treating both males and 
females in the following clinical dosage schedule: 900 mg initially, followed by 300 mg 
q.i.d. fora total of 5.4 grams. 

For treatment of syphilis, when penicillin is contraindicated, a total of 18 to 24 grams of 
'Rondomycin' (methacycline HCI) in equally divided doses over a period of 10-15 days 
should be given. Close follow-up, including laboratory tests, is recommended. 

Eaton Agent pneumonia; 900 mg daily for six days. 

Children - 3 to 6 mg/lb/day divided into two to four equally spaced doses. 

Therapy should be continued tor at least 24-48 hours after symptoms and fever have 
subsided. 

Concomitant therapy: Antacids containing aluminum, calcium or magnesium impair ab- 
sorption and are contraindicated. Food and some dairy products also interfere. Give drug 
one hour before or two hours after meals. Pediatric oral dosage forms should not be 
given with milk formulas and should be given at least one hour prior to feeding. 

In patients with renal impairment (see WARNINGS), total dosage should be decreased 
by reducing recommended individual doses or by extending time intervals between 
doses. 

In streptococcal infections, a therapeutic dose should be given for at least 10 days. 
SUPPLIED: Rondomycin' (methacycline HCI): 150 mg and 300 mg capsules; syrup con- 
taining 75 mg/5 cc methacycline h6. 

Before prescribing, consuit package circular or latest PDR information. 

Rev. 6/73 

iWWi WALLACE PHARMACEUTICALS 
CRANBURY, NEW JERSEY 08512 


236 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


$6.00 Per Annum, $1.00 Per Copy TTTT V 1 Q1A Published Monthly 

Vol. 126, No. 7 d Xi7(^ 1700 Josephine Street, New Orleans, La. 70113 


Radiation Therapy in Hodgkin’s Disease* 

• The evolutionary development of radiation therapy of Hodgkin's 
disease has been described. High dose, extended field radiation 
treatment with cobalt beam or linear accelerator has become the 
prevailing method of choice. Close cooperation with the hematol- 
ogist or the medical oncologist is mandatory. Under favorable cir- 
cumstances, long-term survival of many patients with Hodgkin's 
disease can now be expected. 


A PERIOD of 63 years separates the 
first report of Thomas Hodgkin in 
1832 and the discovery of x-rays by W. C. 
Roentgen in 1895. Only seven years later, 
in 1902, William Pusey, a dermatologist 
and Gregory Cole, a radiologist, were us- 
ing x-ray therapy in patients known to 
have Hodgkin’s disease. The first statis- 
tical report seems to have been by Arthur 
Desjardins,^ in May 1932, a whole century 
after the report by Hodgkin. Interesting- 
ly, it was presented in New Orleans at an 
annual meeting of the American Medical 
Association. 

In his report, Desjardins recommended 
irradiation of involved lymph nodes and 
adjacent areas with therapy in the 140 KV 
range. He wrote: “Almost invariably, the 
effect of treatment is rapid reduction in 

* Presented at the American College of Physi- 
cians Postgraduate Course, “Clinical Application 
of Recent Advances in Medicine” at Ochsner 
Medical Center, New Orleans, January 21, 1974. 

t Director of Department of Radiation Ther- 
apy, Ochsner Medical Center, New Orleans, Lou- 
isiana. 

Reprint requests to Dr. Ochsner, 1516 Jeffer- 
son Highway, New Orleans, Louisiana 70121. 


SEYMOUR FISKE OCHSNER, MDf 

New Orleans 

size of the enlarged lymph nodes in the 
irradiated regions.” In the light of our 
present practice it is interesting to read 
these additional thoughts by Desjardins: 

Roentgen treatment may be given by one of 
two methods. Either irradiation may be confined 
to regions in which enlarged nodes can actually 
be palpated, or it may be somewhat more general 
at the onset and later restricted. . . The second 
method of treatment is preferable for the ma- 
jority of patients who, presenting cervical and 
axillary, cervical, axillary and mediastinal, or 
inguinal, may be presumed to have . . . abdom- 
inal involvement as well. 

More Modern Concepts of Treatment 

The general practice in radiation ther- 
apy in the 1930s was treatment to the 
involved lymph nodes, usually in doses of 
about 1000 roentgens, with the aim of pro- 
ducing disappearance of enlarged or symp- 
tomatic nodes. As experience increased, 
however, radiotherapists became more ag- 
gressive in their treatment schedules. In 
1939, the Swiss radiologist, Gilbert,^ rec- 
ommended “segmental therapy,” and noted 
the increasing survival rates with more 
extensive treatment. In 1947, Memer and 
Stenstrom^ reviewed a large series at the 


July, 1974 — Vol. 126, No. 7 


237 


RADIATION THERAPY— OCHSNER 


University of Minnesota and recommended 
local treatment up to 2000 rads. In 1950, 
Peters* of the Princess Margaret Cancer 
Institute in Toronto made a significant 
contribution, by introducing the concept 
of “prophylactic” irradiation of adjacent 
areas to the involved lymph nodes. Her 
statistics indicated that such treatment 
increased survival in Stage II lesions by 
13 percent and in Stage III lesions by 17 
percent. In 1952, in a monograph based on 
data from Memorial Hospital, Graver^ 
stressed the concept of Hodgkin’s disease 
being a unicentric disease, which was 
therefore potentially curable by radical 
surgical or radiotherapeutic techniques. 
Additional experience with surgical ex- 
cision of masses of Hodgkin’s disease con- 
vinced most surgeons that such treatment 
was not curative or effective. 

In 1963, Baum and coworkers® intro- 
duced the concept of a pretreatment eval- 
uation consisting of lymphangiography, 
cavography, and urography, as methods 
of identifying the frequent abdominal, 
retroperitoneal nodal involvement. The in- 
troduction of Lukes’ histological classifi- 
cation of Hodgkin’s in 1963,^ the Rye Con- 
ference on Hodgkin’s disease in 1966,® and 
the refinement of clinical staging at a con- 
ference at Ann Arbor® are significant con- 
tributions of the recent past. 

Radical Radiotherapy 

Credit must go to Kaplan*® for introduc- 
ing in 1962 the concept of radical radio- 
therapy with extended fields in the treat- 
ment of apparently localized Hodgkin’s 
disease. He introduced the program which 
has become known as the “mantle tech- 
nique,” treating the nodal areas on either 
side of the diaphragm with a large, con- 
tinuous, shaped field and carrying the dose 
to 3500 to 4000 rads in three to four weeks 
of treatment. After a rest period of four 
to six^ weeks, a similar dose was adminis- 
tered to the nodes on the other side of the 
diaphragm. This is very strenuous treat- 
ment. As Kaplan was to comment later: 

Five years ago, I would havei regarded our 
present treatment of virtually every lymph node 


in the body to 4000 rads in four weeks to the 
upper one-half of the body and then 4000 rads 
subsequently to the lower one-half of the body 
as insane. But this is now being done without 
apparent serious injury to the patients. 

High dose, extended field -programs 
have now become popular in most radio- 
therapy centers.** Bagshaw, Kaplan, and 
Rosenberg*® wrote a progress report on 
extended field radiation in 1968, and a 
new monograph by Kaplan*® gives a wide 
ranging discussion about the methods, re- 
sults, and complications of high dose, large 
field radiation therapy in Hodgkin’s dis- 
ease. 

Voices of Doubt 

Let us record, however, that there are 
voices of doubt about the need or wisdom 
of giving such large doses of radiation to 
such extensive areas of the body. Lampe 
and coworkers,** studying results at the 
University of Michigan, indicated that 
their high dose program of 2000 rads in 
two weeks produced overall results as fa- 
vorable as those reported after higher 
doses. More recently, Hope-Stone*® wrote: 
“Prophylactic irradiation is of no great 
value in improving the prognosis,” as com- 
pared with results when using their stan- 
dard method of treating the lymph nodes 
involved with a 5 cm margin in every di- 
rection. He also reported that the first 
recurrence took place as commonly in the 
prophylactically treated areas as it did in 
the adjoining lymph node area when no 
prophylaxis was given. 

He summarized the many disadvantages 
to prophylactic irradiation: irradiation 

sickness, leukopenia, dryness of mouth, 
impairment of taste, radiation pneumoni- 
tis, radiation myelitis, damage to kidneys, 
intestine, or bone, and lowering of immune 
response. These factors, in the long run, 
will have to be balanced against the possi- 
bility of increasing the useful survival 
time of the prophylactically treated pa- 
tients. Many therapists feel that initial 
experience already indicates this benefit, 
while others, like Hope-Stone, find “The 
value ... is still very much in doubt.” 

It should be noted that Hope-Stone does 


238 


J. Louisiana State M. Soc. 


RADIATION THERAPY— OCHSNER 


believe that some Hodgkin’s patients can 
be cured and that the preferred dose (in 
megavoltage) is 2850 rads, localized treat- 
ment in two weeks. 

In one large cooperative study, under 
the chairmanship of Nickson,^® several 
hundred patients have been randomly 
placed into two groups and treated with 
localized (involved field) or widespread 
(extended field) radiation therapy. This 
study suggests that more limited field ap- 
proach is as effective in survival rates 
and results in fewer complications than 
does the extended field approach. 

Discussion 

In a sense, the thoughtful radiotherapist 
carries out his current program with hope- 
ful enthusiasm on one hand and with de- 
liberate hesitancy on the other. Anyone 
familiar with past episodes of damage to 
human beings that resulted from over- 
enthusiastic, or injudicious, or erroneous 
radiation therapy must approach every 
new recommendation for “radical” treat- 
ment with a sense of caution. The imme- 
diate result is not the whole answer. Ten 
years, even 20 years, must pass before a 
final judgment will be forthcoming. Mean- 
while, we who practice today must make 
decisions about how to proceed today. 

So long as we have much intimate inter- 
action with our hematologic colleagues, it 
has seemed to me justifiable to participate 
in a closely controlled effort to put into 
use the program of prolonged, high dose, 
extended field therapy with megavoltage 
beam irradiation. 

In general, this requires cobalt or super- 
voltage apparatus, so that large areas can 
be covered in a single field of irradiation 
and so that the beam used is penetrating 
enough to provide a satisfactory dose of 
irradiation in the depths of the body. It 
requires comprehensive treatment plan- 
ning that rarely can be accomplished with- 
out the continuing support of a physicist 
and dosimetrist. Shaping the beam so that 
appropriate shielding is provided for the 
spinal cord, larynx, lungs, kidneys, and 
gonads is very important. Careful control 


of the fields of irradiation is maintained 
with radiographs made with the treatment 
beam and precision in daily reproducibil- 
ity of the set up is mandatory. We aim at 
a dosage of 1000 rads per week, with at- 
tention to such details as prompt sympto- 
matic treatment for minor discomforts 
and pausing in treatment if the WBC falls 
below 2,000 or the platelet count below 
50,000. In some patients it is necessary to 
give the patient a rest of one or two weeks 
in the middle of the month-long irradia- 
tion. Indeed, this split course of treatment 
is recommended by some.^® A rest inter- 
val of one or two months is usually per- 
mitted between the upper mantle and low- 
er extension courses of treatment. 

Based on six years of continuing experi- 
ence, we may say that most patients seem 
to tolerate the treatment fairly well and 
return to normal activities in several 
weeks. A preliminary survey of gross sur- 
vival statistics has been undertaken three 
years after completion of extended field 
therapy. Among 15 patients in Stage I, 
14 were living and well (94%). Among 
11 patients with Stage II disease, 9 are 
alive and well (82%). Among 15 patients 
with Stage III disease, 8 are alive and well 
(53%). 

Successful radiation therapy of Hodg- 
kin’s disease demands close cooperation 
between the radiotherapist and the hema- 
tologist or the medical oncologist. The 
initial appraisal before radiation therapy 
must be exacting. The use of staging lapa- 
rotomy must be considered. The manage- 
ment of general medical problems must be 
prompt. Decisions about initial or subse- 
quent chemotherapy must be faced. Ra- 
diation therapy is not planned or accom- 
plished in a clinical vacuum, and coopera- 
tive planning with a knowledgeable intern- 
ist is an absolute necessity. 

Referencese 

1. Desjardins AU : Radiotherapy for Hodgkin’s dis- 

ease and lymphosarcortla. JAMA 99:1231-1236, 1932 

2. Gilbert R: Radiotherapy in Hodgkin’s diease (ma- 
lignant granulomatosis); anatomic and clinical foundation; 
governing principles ; results. Am J Roentgenol Radium 
Ther Nucl Med 41 :198-241, 1939 


July, 1974— Vol. 126, No. 7 


239 


RADIATION THERAPY— OCHSNER 


3. Merner TB, Stenstrom KW : Roentgen therapy in 
Hodgkin’s disease. Radiology 48:355-368, 1947 

4. Peters MV : A study of survivals in Hodgkin’s dis- 
ease treated radiologically. Am J Roentgenol Radium Ther 
Nucl Med 63:299-311, 1950 

5. Graver LF: Value of early diagnosis of malignant 
lymphomas and leukemias. Ed 1, New York, American 
Cancer Society, 1952, p 47 

6. Baum S, Bron KM, Wexler L, et al: Lymphangi- 
ography, cavography and urography; comparative ac- 
curacy in the diagnosis of pelvic and abdominal metas- 
tases. Radiology 81:207-218, 1963 

7. Lukes RJ : Relationship of histologic features to 

clinical stages in Hodgkin’s disease. Am J Roentgenol 
Radium 'Ther Nucl Med 90:944-955, 1963 

8. Rye Conference on Hodgkin’s Disease. Cancer Res 
26:1045-1311, 1966 

9. Carbone PP, Kaplan HS, Musshoff K, et al : Report 
of the committee on Hodgkin’s disease staging classifi- 
cation. Cancer Res 31 :1860-1861, 1971 


10. Kaplan HS: The radical radiotherapy of regionally 
localized Hodgkin’s disease. Radiology 78:553-561, 1962 

11. Johnson RE: Updated Hodgkin’s disease: B. 
Curability of localized disease. Total nodal irradiation. 
JAMA 223:59-61, 1973 

12. Bagshaw MA, Kaplan HS, Rosenberg SA: Ex- 
tended-field radiation therapy in Hodgkin’s disease: A 
progress report. Radiol Clin North Am 6:63-70, 1968 

13. Kaplan HS: Hodgkin’s Disease. Harvard Univer- 
sity Press, Cambridge, 1972 

14. Fayos J, Hendrix R, MacDonald V, et al: Hodg- 
kin’s disease. A review of radiotherapeutic experience. 
Am J Roentgenol Radium Ther Nucl Med 93:557-567, 
1965 

15. Hope-Stone HF: The treatment of reticulosis. Br 
J Radiol 42:770-783, 1969 

16. Nickson JJ: Report at meeting of American So- 
ciety of Therapeutic Radiologists, October 28, 1973, New 
Orleans 




HiBeRnia 

/ li J nanonai 

eariK 


240 


J. Louisiana State M. Soc 



Chondrosarcoma of the Maxilla: Surgery and 
Reconstruction 


• "A plan is suggested for wide resection and a team approach for 
immediate reconstruction with improved rehabilitation.” 


^HE unnerving discovery of a malig- 
nant tumor on the face of a young fe- 
male patient must by its urgency raise 
serious questions in the mind of the physi- 
cian. What are the nature of this tumor 
and its prognosis? What is the best mode 
of therapy? 

The pathos of the tearful announcement 
on the first postoperative visit “my baby 
would not come to me” must lead to the 
query .... is the surgical procedure we 
have performed the one most likely to 
allow this patient to be successfully re- 
habilitated and enjoy her parenthood for 
years to come? 

Such was the case that prompted this 
paper. An early and accurate diagnosis by 
the first examiner, a radical and complete 
surgical approach, and a combined effort 
toward rehabilitation — these features we 
propose as the satisfying sequel to this 
scene. 

Case History 

The patient, a 35-year-old Negro woman, was 
admitted to the LSU Otolaryngological Service at 
Charity Hospital in May of 1971 on referral from 
her dentist. She related a five week history of a 
tender swelling over her left cheek. When this 
persisted with bleeding on brushing her teeth, she 
had seen the dentist whose suspicions were 
aroused. A biopsy was taken and reported as 
chondrosarcoma. 

On admission, a raised, ulcerative lesion 2.0 by 
3.0 cm was seen on the left maxillary alveolar 
ridge originating at the area of the second molar. 
This firm lesion could be palpated extending up 
onto the maxilla and as far posteriorly as the 
maxillary tubercle. There was no palpable cer- 


Reprint requests to Department of Otorhino- 
laryngology, Louisiana State University School of 
Medicine, 1542 Tulane Avenue, New Orleans, 
Louisiana 70112. 


PAUL R. ZEHNDER, MD 
GEORGE D. LYONS, MD 
New Orleans 

vical adenopathy. The remainder of the physical 
examination and preoperative evaluation was 
normal. 

Tomography of the maxilla revealed erosion of 
the lateral maxillary wall. In order to delineate 
the extent of this tumor, a diagnostic maxillary 
antrotomy was performed. The mucosa of the 
sinus was intact. A firm rounded mass was seen 
on the inferior-lateral wall of the sinus. Biopsies 
of this area were positive. The remainder of the 
biopsies from the walls of the sinus was negative. 

The patient was seen by our consulting prostho- 
dontist. Initial impressions were made for a 
prosthesis based on our proposed surgical excision 
and the patient’s dentition of the opposite side. 

A modified Weber-Ferguson incision was em- 
ployed eliminating the infraorbital hmb, and a 
left subtotal maxillectomy was performed. The 
cavity was lined with split-thickness graft from 
the thigh. 

The postoperative course was uncomplicated. 
The patient took fluids on the second postopera- 
tive day and tolerated soft foods on the fourth. 
She was allowed to return home on the eighth 
day. Her speech and swallowing were excellent; 
this was very reassuring to the patient. A perma- 
nent prosthesis with an obturator to improve the 
contour of her cheek is being fashioned. (Fig 
1-4.) 



Fig 1. Surgical specimen, subtotal maxil- 
lectomy with tumor above molar. 


July, 1974— Vol. 126, No. 7 


243 


CHONDROSARCOMA— ZEHNDER, ET AL 



Fig 2. Postoperative surgical cavity. 



Fig 3. Temporary prosthesis. 



Fig 4. Postoperative appearance with pros- 
thesis in place. Modified Weber-Ferguson scar in 
upper lip. 


Review of Literature 

Incidence 

Benign or malignant neoplasms of chon- 
dromatous origin are rare in the head and 
neck area. Chondromas and chondrosar- 
comas are most frequently found to in- 
volve the long bones, pelvis, sternum, scap- 


ula and bones of the hands and feet. The 
incidence of chondrosarcomas of the skull 
according to Henderson and Dahlin^ com- 
prises 1.25 percent of all chondrosarcomas. 
To date, there are 30 reported cases of 
chondrosarcomas of the maxilla in the 
literature.^’ 

Clinical Pathological Findings 

Chondrosarcoma has been accepted as a 
distinct pathological entity from osteo- 
genic sarcoma since 1939. The basis ana- 
tomic difference is that chondrosarcomas 
develop out of full-fledged cartilage, 
whereas osteogenic sarcoma has its origin 
in a more primitive tissue, bone forming 
mesenchyme.® 

The existence of a cartilaginous tumor 
in the maxilla which is generally accepted 
as membrane bone has been a source of 
confusion to some. The theories proposed 
are as follows: 

1. There is no appreciable difference 
between chondroblasts and osteoblasts, 
perhaps allowing transformation. 

2. A site of secondary cartilage may be 
found in relation to maxillary molar teeth. 

3. Tissue resembling cartilage and 
termed chondroid has been found in areas 
of rapid growth, including the upper and 
lower jaws. 

4. Vestigial rests may remain because 
of the close relation of the chondrocranium 
or cartilage from around the septum may 
become trapped in bone.®’ * 

Of considerable interest is the high num- 
ber of patients who presented with a mass 
in the jaw which produced symptoms re- 
lating to their teeth or dentures. This 
prompted a dental visit, where we would 
hope an early diagnosis could be made as 
happened in our case. 

Several authors^ ®’ have pointed out 
that previous biopsies on these patients 
have been reported as benign chondroma 
or osteochondroma. The correct diagnosis 
was made only after complete excision or 
recurrence. Because of this, chondroma- 
tous tumors of the head and neck should 
be viewed with a high index of suspicion. 


244 


J. Louisiana State M. Soc. 





CHONDROSARCOMA— ZEHNDER, ET AL 


There can be a great deal of variety in 
appearance of cartilaginous tumors, and it 
is apparent that the malignant character 
has been underestimated in the past. In 
many chondrosarcomas, it is possible from 
the clinical course and radiographic and 
pathologic findings to deduce that these 
lesions were originally considered benign. 

The criteria for malignancy have been 
pointed out: 1) many cells with plump 
nuclei; 2) more than an occasional cell 
with two such nuclei; and especially 3) 
giant cartilage cells with large single or 
multiple nuclei or with clumps of chro- 
matin.® 

The clinical course of these tumors is 
that of aggressive local extension with 
pressure destruction as the neoplasm ex- 
pands. There is a marked tendency to 
recur after inadequate surgery, and fatal 
widespread metastasis has been reported 
in long-standing cases. 

Treatment 

The treatment for chondrosarcoma is 
radical resection. Radiation is of little 
value, since this type of tumor is highly 
radio-resistant.®’ ® 

The prognosis for these tumors is vari- 
able, depending on size and location, 
amenability to surgical resection and his- 
tological characteristics of the tumor. The 
largest reported series had a five year sur- 
vival for maxillary lesions of 60 percent.® 
A more accurate prognosis could be made 
if analysis and classification of location 
were on a more scientific basis. A pro- 
posed TMN classification^^ is based on di- 
vision of the skull into a superior, middle 
and inferior region. According to this 
classification, it would seem likely that a 
patient such as the one in our case involv- 
ing the infrastructure of the maxilla would 
have a better prognosis. 

Discussion 

A young mother with a malignant tumor 
of the facial skeleton is encountered, and 
her management differs in that immediate 
rehabilitation is accomplished in one stage. 

The primary concern to the cancer sur- 


geon must always remain the eradication 
of disease, but the physiological, cosmetic 
and subsequent psychological problems of 
the patient have also assumed a role of 
demanding importance. 

The cosmetic and psychological advan- 
tages are obvious. From a physiological 
standpoint, feeding is possible without 
nasogastric intubation and nasal regurgi- 
tation. Normal speech can be maintained 
by assuring velopharyngeal competence. 

Improved surgical techniques, the devel- 
opment of adaptable prosthetic devices 
and the team approach have made imme- 
diate reconstruction at the time of surgery 
not only a possibility but a necessary con- 
sideration. 

Summary 

Chondrosarcoma of the maxilla is a rare 
tumor. The literature points out that sur- 
gery is the treatment of choice, irradia- 
tion almost ineffective and that early rec- 
ognition and complete removal offer a 
good chance for cure. 

A plan is suggested for wide resection 
and a team approach for immediate recon- 
struction with improved rehabilitation. 
This should be considered as a matter of 
course in all cases such as this. 

References 

1. Henderson ED, Dahlin DC: Chondrosarcoma of 

bone — a study of 288 cases. J Bone Joint Surg 45:1450, 
1963 

2. Batsakis JG, Dito WR: Chondrosarcoma of the 

maxilla. Arch Otolaryng 75:69-75, 1962 

3. Sandler HC : Chondrosarcoma of the maxilla; Re- 

port of a case. Oral Surg 10:97-104, 1957 

4. Goldman RL, et al: Extraosseous chondrosarcoma 

of the maxilla. Arch Surg 95:301-303, 1967 

5. Arlen M, Toleefsen BLR, et al: Chondrosarcoma of 
the head and neck. Amer J Surg 120:456-60, 1970 

6. Curphey JE: Chondrosarcoma of the maxilla: report 
of a case. J Oral Surg 29:285-90, 1971 

7. Ewing JA : A review of the classification of bone 
tumors. SGO 68:971-976, 1939 

8. Lichtenstein L, Jaffe HL: Chondrosarcoma of bone. 
Am J Pathol 19:553-589, 1943 

9. Aretsky PJ, et al : Chondrosarcoma of the nasal 

septum. Ann Otol 79:382-88, 1970 

10. Kragh LV, et al: Cartilaginous tumors of the jaws 
and facial regions. Amer J Surg 99:852-56, 1960 

11. Paterson W: Chondrosarcoma of the maxilla. J 

Laryng 69:132-39, 1955 


July, 1974— Vol. 126, No. 7 


245 


CHONDROSARCOMA— ZEHNDER, ET AL 


12. Lederman M: Tumors of the upper jaw: natural 
history and treatment. J Laryng 84:369-401, 1970 

13. Lapidot A, et al: Chondrosarcoma of the maxilla. 
J Laryng 80:743-47, 1966 

14. Ash JE, Beck MR, Wilkes JD: Tumors of the 

upper respiratory tract and ear. Atlas of tumor pathology, 


Sect 4, Ease 12-13. Armed Forces Institute of Pathology, 
Wash. D.C., 1964 

15. Maccomb WS, Fletcher GH: Cancer of the Head 
and Neck. Williams and Wilkins, Baltimore, 1967, pp 
329-356, 517-537 

16. Converse JM (ed) : Reconstructive Plastic Surg 

vol 3, pp 1038-52, W.B. Saunders, Philadelphia, 1964 





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246 


J. Louisiana State M. Soc. 







Hemochromatosis 


• Hemochromatosis is an iron storage disease characterized by 
excessive tissue iron in many parenchymal organs and saturation 
of iron binding plasma protein. Clinical manifestations are related 
to damage produced by the overload and include cirrhosis of the 
liver, diabetes, myocardial insufficiency, and arthritis. Primary 
hemochromatosis is familial and thought to be due to a recessive 
gene with variable manifestations in heterozygotes. Secondary 
hemochromatosis results from exogenous iron overload due to 
increased intake or abnormal stimulus for absorption. Treatment 
is removal of excess iron, preferably by multiple phlebotomies, 
although dietary agents may be of some help. Depletion of iron 
stores to normal results in clinical improvement, especially in hepatic, 
cardiac, and skin manifestations as well as marked increase in 


energy, well-being, and longevity. 


XJEMOCHROMATOSIS may be de- 
fined as an iron storage disease 
which is characterized by excessive tis- 
sue iron in many parenchymal organs, 
saturation of the plasma iron-binding 
protein, and various combinations of 
cirrhosis of the liver, diabetes, bronze 
skin, myocardial insufficiency, and more 
recently elucidated, arthritis, chondro- 
calcinosis, and exocrine pancreatic in- 
sufficiency.^ The total body iron may be 
ten times the normal 3 to 5 gms while 
the liver and pancreatic iron may be 
50 to 100 times normal, the heart 10 to 
15 times, the spleen, kidney, and skin 
about 5 times. 

Primary or familial hemochromatosis 
is due to failure of the intestinal mucosa 
to insulate the organism from unneeded 
ingested iron and is characterized by 
elevated serum irons and saturated iron 
binding capacities in many relatives of 
symptomatic patients, together with oc- 
currence of the full blown disease in 
siblings and successive generations. The 
clinical picture develops as iron slowly 


From the Department of Internal Medicine, 
Section on Gastroenterology, Ochsner Clinic and 
Ochsner Foundation Hospital, New Orleans. 

Reprint requests to Dr. Davis, 1514 Jefferson 
Highway, New Orleans, Louisiana 70121. 


WILLIAM D. DAVIS, JR., MD 
New Orleans 

accumulates over the years with resulting 
cirrhosis, diabetes, congestive heart fail- 
ure, bronzing of the skin, hypogonadism 
and arthritis in various combinations. 

The genetic mechanism obtaining in 
primary hemochromatosis is best con- 
sidered to be due to a recessive gene 
with variable manifestations in hetero- 
zygotes.2 A number of families of these 
patients have been studied in whom 
neither alcohol, anemia, excessive die- 
tary intake of iron, multiple blood trans- 
fusions, or parenteral iron can be impli- 
cated. 

In primary hemochromatosis, in con- 
trast to the normal, dietary iron is taken 
into the intestinal mucosal cell as ferri- 
tin and instead of being shed with the 
cell as normally occurs when body iron 
stores are full and transferrin saturated, 
it enters the circulation and is apparent- 
ly cleared almost totally in its initial 
passage through the liver. There, it 
arrives at parenchymal cells where, be- 
cause of saturated transferrin, it exists 
in a relatively unbound (ionic) and dam- 
aging form, a situation which according 
to Wheby^ is a likely explanation for the 
development of hepatic cell damage and 
cirrhosis. Recent studies have demon- 
strated also that there is a tendency in 


July, 1974— Vol. 126, No. 7 


247 


HEMOCHROMATOSIS— DAVIS 


patients with hemochromatosis to con- 
tinue to absorb iron in larger amounts 
than normal.^'® High levels of serum 
ferritin® and demonstration of an unusual 
pattern of tissue isoferritin'^ in hemo- 
chromatosis tend to confirm these views. 
Distribution of the iron is predominantly 
within the peripheral lobular liver cells 
but also in the ductular epithelium and 
the fibrous tissue in the liver, as well as 
the parenchymal cells of other epithelial 
organs, the myocardium, lymph nodes, 
and spleen. 

In secondary hemochromatosis, the 
iron enters as a result of increased ab- 
sorption related to certain anemias, 
excess iron ingested as a result of food 
preparation in iron utensils, high iron 
content of certain wines and liquors, or 
therapeutically administered oral or 
parenteral iron. Unknown mechanisms 
operative in pancreatic insufficiency, 
porta caval shunt, and perhaps related 
to altered dietary constituents may also 
contribute. In this type of hemochroma- 
tosis, particularly when the pathway of 
entrance of the iron has been parenteral, 
spleen and lymph nodes seem to be load- 
ed early and the full clinical picture, 
including loading of the hepatic paren- 
chymal cells to the same extent as the 
primary type, appears only in those in- 
stances in which massive overload has 
been achieved. 

The classical clinical manifestations — 
cirrhosis, diabetes, and bronzed skin — 
are seen in approximately two-thirds of 
patients with primary hemochromatosis 
who have lived long enough, but both 
the skin manifestation and the diabetic 
state may be absent in as many as 20 to 
25 percent of this group. The stigmata 
of cirrhosis and the complications of 
diabetes characterize the later course of 
the disease. Abdominal pain of a kind 
resembling biliary colic is not infre- 
quently seen, and heart failure related 
to myocardial insufficiency is a frequent 
cause of death, particularly in the 
younger patient group. A rheumatoid- 


like arthritis with synovitis is not infre- 
quently seen,® and cases of chondrocal- 
cinosis with pseudogout have also been 
reported. Pancreatic exocrine insuffici- 
ency also has recently been reported. 
Suspicion of hemochromatosis should be 
aroused by the presence of a firm, 
smooth enlarged liver not otherwise 
easily explained. While much more 
common in men, it does occur in women 
but usually tends to present 10 to 15 
years later in life because of excessive 
iron needs in the female. 

In younger persons unexplained con- 
gestive heart failure, especially if diffi- 
cult to control, should arouse suspicion. 
The presence of a dark skin hue, more 
usually slate gray, and diabetes are also 
suggestive. Serum iron studies will re- 
veal high levels with near saturation of 
iron binding capacity and frequently 
slight lowering of the total iron binding 
protein. 

Liver biopsy with the classical cirrho- 
sis and heavy iron pigment deposition is 
diagnostic. The demonstration of hemo- 
siderin granules in gastric mucosal biop- 
sies, shed bladder epithelial cells and 
bone marrow preparations also are most 
helpful. 

Treatment, in addition to management 
of diabetes and support for the liver, in- 
cludes mobilization of iron. By far the 
most effective method is by use of mul- 
tiple phlebotomies at the maximum rate 
which the patient’s bone marrow can re- 
generate, usually from 500 to 1,000 ml 
per week.® Where lack of protein is a 
problem, the cells may be separated and 
the plasma re-infused. Such a technique 
may remove approximately 25 gm of iron 
in a year, an amount which is near the 
therapeutic goal for most patients. Evi- 
dences of iron deficiency mark an end 
point at which frequency of phlebotomy 
may be reduced to a maintenance pro- 
gram of perhaps every six to eight or ten 
weeks. The use of iron-binding chelating 
agents, although effective in removing 
relatively small amounts of iron, are not 


248 


J. Louisiana State M. Soc. 


HEMOCHROMATOSIS— DAVIS 


of much use for the overwhelming job 
needed for most of these patients. In 
those instances in which blood regenera- 
tion limits the iron mobilization, how- 
ever, deferoxamine (Desferal®) will re- 
move iron effectively but at a slow rate. 

Results of treatment are, in general, 
excellent with the patients usually re- 
porting an increase in well-being after 
a few weeks of treatment. Liver func- 
tion tests improve after several months; 
diabetes may improve but does not in- 
variably do so. An interesting recent 
observation has shown that the usually 
elevated volume and total bicarbonate 
response to secretin stimulation of the 
pancreas in hemochromatosis is returned 
to normal in phlebotomized patients.^® 
A number of observations have been 
recently made which document remark- 
able improvement in myocardial func- 
tion with return of cardiac output and 
exercise tolerance to normal in patients 
who formerly exhibited profound insuf- 
ficiency.^^ Unfortunately, the arthritis 
does not respond in similar manner. 
Primary carcinoma of the liver is a 
rather frequent complication which is 
not completely protected against by 
phlebotomy begun after development of 
cirrhosis. It is one of the more common 
causes of death in middle or late life. 
Whether identification of potential he- 
mochromatosis patients through serum 
iron studies of families and maintenance 
of normal iron levels will prevent this 
complication remains hoped for but 
must be answered by future investiga- 
tion. 

References 

1. Finch SC, Finch CA: Idiopathic hemochromatosis. 
An iron storage disease. Medicine 34:381-430, 1955 

2. Scheinberg IH: The genetics of hemochromatosis. 
Arch Intern Med 132:126-128, 1973 

3. Wheby MS: Iron and liver damage. Clin Res 19:76, 
1971 

4. Sargent T, Saito H, Winchell HS: Iron absorption 
in hemochromatosis before and after phlebotomy therapy. 
J Nucl Med 12 :660-667, 1971 

5. Powell LW, Campbell CB, Wilson E: Intestinal 

mucosal uptake of iron and iron retention in idiopathic 
hemochromatosis as evidence for a mucosal abnormality. 
Gut 11:727-731, 1970 

6. Walker RJ, Beamish MR, Jacobs A, et al: Serum 


ferritin as a measure of body iron in primary idiopathic 
haemochromatosis. Gut 14:420-421, 1973 

7. Powell LW, Alpert E, Drysdale JW, et al: Abnor- 
mality in tissue ferritin in idiopathic hemochromatosis. 
Proc Am Assoc Study Liver Dis, October 1973 

8. Walker RJ, Dymock IW, Ansell ID, et al: Synovial 
biopsy in haemochromatosis arthropathy. Ann Rheum Dis 
31:98-102, 1972 

9. Davis WD Jr, Arrowsmith WR: The treatment of 
hemochromatosis by massive venesection. Ann Intern Med 
39 :723-734, 1953 

10. Simon M, Gestelin M, et al: Functional study of 
exocrine pancreas in idiopathic hemochromatosis untreated 
and treated by venesection. Digestion 8:481-496, 1973 

11. Easley RM Jr, Schreiner BF Jr, Yu PN : Re- 

versible cardiomyopathy associated with hemochromatosis. 
N Engl J Med 287 :866-867, 1972 




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July, 1974— Vol. 126, No. 7 


249 



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Xeroradiography of the Breast 


VERORADIOGRAPHY, a relatively 
new radiologic modality, is now 
available as a useful, accurate adjunct 
for the clinical physician in the overall 
diagnosis and management of patients 
with breast disease. It is particularly 
helpful in the differentiation between 
benign and malignant tumors and, with 
proper interpretation, can play an inte- 
gral part in the management of such 
patients. 

Case Report 

A 65-year-old white woman had been followed 
elsewhere for a known lump in the left breast 
for several years. The lump began to increase 
in size, and she was referred to the Ochsner 
Medical Center for evaluation. Xerograms of 
the breast (Figs 1 and 2) revealed a lesion in 
the upper half of the breast. The tumor was an 
irregular mass of varying density with a spicu- 
lated border. A few minute calcifications could 
be detected within the tumor itself. Biopsy and 
subsequent left radical mastectomy revealed an 
infiltrating ductal adenocarcinoma. One of 16 
axillary lymph nodes contained metastatic tumor. 

Xeroradiography Process 

An electrically-charged selenium- 
coated aluminum plate encased in a 
cassette is used as a substitute for an 
x-ray film cassette and is exposed to an 
x-ray beam passed through the breast 
in the usual manner. This results in par- 
tial discharge of the plate proportional 
to the x-ray dosage received after the 
rays have traversed the varying thick- 
nesses and densities of the breast, its 
supporting structures, ribs, etc. The la- 
tent electrostatic charge-image is then 
made visible by spraying the plate with 
a fine, blue powder (of opposite charge). 


From the Department of Diagnostic Radiology, 
Alton Ochsner Medical Foundation and Ochsner 
Clinic, New Orleans. 


RALPH B. BERGERON, MD 
New Orleans 

called toner. The visible image is then 
transferred from the plate to a paper for 
interpretation, permanent record, and 
filing. The aluminum plate can be 
cleaned, discharged completely, and 
reused. 


Characteristics of Images 

Xerographic images are different 
from conventional x-ray films. Xero- 
graphs are normally like photographic 



Fig 1. Lateral view of the breast. Note the 
large malignant tumor in the upper half of the 
breast. It is a poorly-defined mass with tumor 
“tentacles” infiltrating the surrounding tissue. 
On the original xerogram, minute calcifications 
could be seen within the lesion. 


July, 1974— Vol. 126, No. 7 


251 


RADIOLOGY PAGE 



Fig 2. Craniocaudad view of the left breast, again clearly delineating the malignant tumor in the 
breast. 


positives whereas x-ray films are nega- 
tives. Xerographs will also show the 
“edge effect.” This effect is an enhance- 
ment of the contrast at the margin of 
varying densities. This can be seen as a 
white border around the skin surface of 
the breast on the xerograms above. This 
is due to the fact that the toner attract- 
ing fields from the electrostatic image 
are strongest at such boundaries. 

Advantages 

1. Greater resolution, permitting iden- 
tification of smaller structures. 

2. All structures within the breast are 
recorded and visualized on one image. 

3. More easily interpreted without spe- 
cial means of viewing. 

4. It is a rapid dry process. 

Clinical Applications 

Xeroradiography can and should be em- 
ployed in any patient who presents with 
a problem related to the breast, particu- 
larly if the patient is in the cancer age 
group or if a mass or some other abnor- 
mality is detectable clinically. It is very 
useful in the evaluation of large, pendu- 
lous breasts as it can detect small, deep 
lesions which are not palpable. It is an 
excellent means of evaluating the remain- 


ing breast in a patient who has had a 
mastectomy for malignancy. 

The xeromammograms are a supple- 
ment to the clinician and/or surgeon and 
should never replace a competent physi- 
cian evaluation. In view of the fact that 
approximately 4 to 8 percent of cancers 
are not identified by the xeroradiographic 
process, a negative report by the radiolo- 
gist should not delay biopsy if a clinically 
suspicious mass is present. However, a 
negative report may help to reinforce a 
clinical impression. Accuracy in diagnosis 
depends in large measure on the age and 
density of the breast. In the younger age 
groups, the breasts are composed of mostly 
glandular elements; and small soft-tissue 
tumors can easily be obscured. This is 
also true in those breasts affected with 
adenosis and/or other forms of mammary 
dysplasia. In the older age groups where 
the breast tissue has largely undergone 
involution and has been replaced by fat, 
small tumor masses become more obvious 
and quite distinct on the xerograms. 
False-positive reports average 6 to 10 per- 
cent, according to Dr. John E. Martin of 
Houston. 

Reference 

1. Wolfe JN : Xeroradiography of the Breast. Spring- 
field, Charles C. Thomas, 1972 


252 


J. Louisiana State M. Soc. 



Medical Grand Rounds 

from 

Touro Infirmary 


A Jaundiced Eye: Gilbert’s Syndrome 

Edited by SYDNEY JACOBS, MD 
New Orleans 


Dr. Robert Baxter: A 15-year-old 

Negro junior high student, regarding him- 
self in excellent health, consulted a surgeon 
five months ago for an athletics depart- 
ment physical examination, and icteric 
sclerae were seen. He had not then 
(or subsequently) experienced nausea, 
vomiting, malaise or fever. He knew of 
no exposure to insanitary environmental 
conditions, had not been involved in al- 
coholic or other drug abuse or in un- 
usual sexual activity. Additionally, he 
had not recently eaten seafood or ever 
received a blood transfusion. His three 
sibling and his parents were not known 
to be “sicklers”. The surgeon deter- 
mined that there was slight elevation of 


the serum indirect bilirubin level with 
normal levels of serum glutamic oxa- 
loacetic transaminase (SCOT) and 
serum glutamic pyruvic acid transam- 
inase (SGPT) ; but started treatment 
for hepatitis with a nutritional diet, vita- 
mins and prolonged bed rest. During 
the succeeding months, frequent blood 
tests indicated persistent elevation of 
bilirubin ; so the patient was not allowed 
to return to school although he was 
completely asymptomatic. Last week 
the patient was referred to an internist 
and was admitted to the hospital for 
evaluation. 

On admission, he was seen to be a 
66I/2 inch, 123 pound, slightly jaun- 
diced black teenager with normal vital 


Intern, Touro Infirmary. 

July, 1974— Vol. 126, No. 7 


253 



MEDICAL GRAND ROUNDS— Touro Infirmary 


signs and a systolic cardiac murmur 
(Grade III) at the apex. Initial studies 
yielded normal values for the follow- 
ing: complete blood count including 
reticulocyte estimation, Ivy bleeding 
time and Lee- White coagulation times, 
prothrombin time, SGOT and SGPT, 
total serum proteins with albumin and 
globulin determinations, blood urea ni- 
trogen, fasting blood glucose, VDRL, 
urinalysis, stool studies for parasites and 
occult blood and two hour urine uro- 
bilinogen excretion. No sickling of ery- 
throcytes was demonstrated. 

The total bilirubin was 2.5 mgm while 
the direct was .3. Chest, gallbladder 
and gastrointestinal x-ray studies and 
radionuclide liver scanning disclosed no 
abnormalities. An electrocardiogram 
was interpreted as showing nothing 
pathological. We could find nothing to 
substantiate a diagnosis of obstructive 
or hemolytic jaundice or of hepatitis; 
so we suspected Gilbert’s disease and 
requested a liver biopsy. This was done, 
and the specimen was reported as show- 
ing normal liver architecture without 
cholestasis or significant cellular abnor- 
mality. 

Dr. Sydney Jacobs: Why was Gil- 

bert’s disease the first choice for diag- 
nosis ? 

Dr. Baxter: Because the patient’s bil- 
irubins were not significantly elevated 
nor was there significant elevation of 
enzymes, and there was no evidence of 
either hemolysis or anemia. 

Dr. Mario Rosemberg: An under- 

standing of the pathophysiology of 
jaundice provides the basis of our clin- 
ical approach to the diagnosis of con- 
stitutional hepatic dysfunction or Gil- 
bert’s disease. Jaundice is the yellow 
discoloration which usually appears in 
the sclera and skin when the serum bili- 


(b) Chief, Department of Medicine, Touro In- 
firmary; Clinical professor of medicine, Tulane 
University School of Medicine. 

(c) pirst year medicine resident, Touro infir- 
mary. 


rubin concentration exceeds 2 to 3 mgms 
per 100 ml. Bilirubin is the end product 
of hemoglobin break-down. The half- 
life of a red blood cell is 120 days. Each 
gram of hemoglobin is approximately 
35 mgms of bilirubin. Once manufac- 
tured by the reticuloendothelial cells, 
bilirubin becomes bound to serum pro- 
tein and reaches the liver where even- 
tually it is discharged into the bile and 
into the intestinal tract. 

In the liver unconjugated bilirubin is 
concentrated, and conjugated with glu- 
curonic acid catalyzed by an enzyme 
that is called glucuronyl transferase in 
the presence of uridine diphosphoglu- 
curonic acid after which it is called di- 
rect bilirubin. After passage through 
the liver into the intestines, bilirubin is 
converted into urobilinogen by the re- 
ducing activity of normal bowel-dwelling 
bacteria. Some urobilinogen is re- 
absorbed in the portal blood and is car- 
ried back to the liver; but a small por- 
tion reaches the general circulation for 
excretion in the urine. Ultimately, the 
daily output of urobilinogen (1 percent 
in the urine and 99 percent in the stool) 
equals the total daily formation of bili- 
rubin, approximately 250 mgms. It is 
most important to stress the fact that the 
parenchymal cells of the liver do not 
manufacture bilirubin from hemoglobin 
but they excrete bilirubin into the bile. 
The bilirubin that is normally found in 
the blood is different from that found in 
the bile. The bilirubin found in the bile 
reacts directly with the diazo reagent 
of van den Bergh’s test. It has therefore 
been called direct or conjugated biliru- 
bin in contrast to the bilirubin found in 
the blood which does not react with this 
reagent except with the assistance of 
some substance such as alcohol. The 
character of the hyperbilirubinemia gen- 
erally reflects the mechanism responsi- 
ble for producing jaundice. 

When there is excessive indirect biliru- 
bin production in hemolytic anemia as a 
result of excessive destruction of RBC 


254 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Touro Infirmary 


and liberation of hemoglobin, there is 
produced acholuric jaundice, ie, one 
does not find bilirubin in the urine. The 
second one is impaired plasma bilirubin 
by the hepatic parenchyma wherein, for 
mechanism that is not explained, the 
liver cells do not take the bilirubin and 
can’t transfer it to conjugated bilirubin. 
A third explanation is reduced hepatic 
conjugation of indirect bilirubin as in the 
hyperbilirubinemia of the newborn or 
in the Dubin- Johnson syndrome where 
there is a deficiency of glucuronyl trans- 
ferase, and the baby is going to have an 
increase in indirect bilirubin. The only 
other explanation is when the liver cells 
can take direct bilirubin and conjugate 
it but the ductal system in the liver does 
not conduct any bile. The other one is 
increased excretion of conjugated bili- 
rubin. It seems that the liver conjugates 
the indirect bilirubin into direct biliru- 
bin, but parenchymal dysfunction will 
not permit it to be normally secreted. 
This is seen in hepatitis or in obstruction 
by tumor or stones. 

Our young man seems to fit in the 
second category. The fact that he did 
not have any evidence of abnormal liver 
function or of hemolysis and that the 
liver tissue was totally normal seems 
to agree with the diagnosis of Gilbert’s 
disease. Originally described in 1901, 
it is supposed to be an autosomal, rela- 
tively common disorder of young men 
although it is not very frequently recog- 
nized in private practice. It is compati- 
ble with normal life span — and is 
marked by intermittent jaundice with 
the level of indirect bilirubin seldom 
exceeding 3 mgms percent accompanied 
by very vague gastrointestinal symp- 
toms. They might present problems 
whenever they have hemolysis from 
some other cause. 

Miss Rhonda Harston:^'^^ When his 
doctor diagnosed “hepatitis,” he told the 
patient to “avoid greasy foods,” and the 
patient adhered faithfully to the pro- 

Staff dietitian, Touro Infirmary. 


gram. He weighs 123 pounds, and his 
“ideal weight” is 126 pounds. His eat- 
ing habits were basically good before 
the diagnosis of “hepatitis” ; so he seems 
to need neither dietary restriction or 
counselling. 

Miss Patricia Roig:^®) He seems to be 
a typical 15-year-old boy with good fam- 
ily relationships. His knowledge of his 
own condition is very limited : he knows 
that he had a biopsy but he doesn’t 
know the result. He had attained 8th 
grade public school level before being 
put at bed rest. 

Dr. Murrel H. Kaplan I think that 
after that scholarly discussion by Dr. Ros- 
emberg, there is not very much that I can 
really add. One function of the microsome 
is to convert unconjugated bilirubin into 
conjugated bilirubin through its uridine 
diphosphoglucuronic acid. In Gilbert’s 
disease, the unconjugated bilirubin in 
the blood barely trickles into the liver 
cell, so that only a certain amount is 
conjugated. There the unconjugated 
bilirubin remains in the blood. In Dubin- 
Johnson disease, unconjugated bilirubin 
going into the cell is adequately conju- 
gated but has difficulty in excretion 
through the bile canaliculi. Consequent- 
ly more direct bilirubin remains in the 
bloodstream in the Dubin-Johnson syn- 
drome. In hemolytic jaundice, we have 
a tremendous amount of unconjugated 
bilirubin coming to the hepatic cells. A 
great deal of it is converted, and so you 
really don’t have any conjugated bili- 
rubin coming back into the blood. In 
the physiological jaundice of the new- 
born, the hepatocytes are immature. 
Unconjugated bilirubin cannot be con- 
jugated adequately in the first four to 
six days, but as the liver cells mature, 
this defect is overcome, and the jaundice 
clears. However, in this pathological 
state, a tremendous amount of uncon- 


Clinical counselor. Social Service, Touro In- 
firmary. 

Clinical professor of medicine, LSU School 
of Medicine. 


July, 1974— Vol. 126, No. 7 


255 


MEDICAL GRAND ROUNDS— Touro Infirmary 


jugated bilirubin, being fat soluble, goes 
into the brain and causes kemicterus of 
the newborn, which frequently kills the 
child. In a discussion of biliary metab- 
olism, one must have a clear conception 
of what is meant by obstruction. In the 
latter, unconjugated bilirubin is convert- 
ed, but it can’t get out of the liver due 
to a blockage of the duct system. In the 
intrahepatic type the microsomes are in- 
jured. Depending on the severity of the 
disease, the parenchyma can’t convert 
all or part of the unconjugated bilirubin. 
One understands then that unconjugat- 
ed bilirubin as well as conjugated bili- 
rubin can be found in the blood. There- 
fore, in so many cases of hepatitis direct 
bilirubin and indirect bilirubin are re- 
ported. Cytologically, it may be possible 
to diagnose Dubin-Johnson disease by 
finding bile pigments in the cell whereas 
one won’t find it in Gilbert’s disease. It 
is very difficult at times to distinguish 
between intra and extrahepatic jaun- 
dice. One cannot always do this by 
looking at the liver profile, ie, the direct 
and indirect bilirubin as well as the 
quantitative enzyme reports. What are 
the characteristics of Gilbert’s disease ? 
The real difficulty may arise when one 
has a patient who is recovering from 
mononucleosis or some type of infection. 

On examination, your patient is noted 
to have icteric sclerae. Has he had viral 
hepatitis — or a complication of mono- 
nucleosis? We have to depend a great 
deal on the enzyme studies, and if the 
transaminase studies are normal, we cer- 
tainly feel that it really is not a patho- 
logical condition. The conclusion that 
this is a case of Gilbert’s disease per- 
mits the patient to enjoy life without 
restrictions. These patients hardly ever 
have any symptoms, except minor ones 
after a febrile illness. I think it was 
most unfortunate for this young man to 
have been at first attended by a physi- 
cian who didn’t realize that elevation of 
the serum bilirubin as an isolated finding 
is not sufficient basis for a diagnosis of 


‘‘hepatitis”. In contradistinction, Dubin- 
Johnson patients can feel bad enough to 
warrant detailed study for differentia- 
tion from chronic hepatitis. Here the 
liver biopsy is most helpful. 

Dr. Jacobs: Dr. Kaplan, have you had 
occasion to follow anyone with Gilbert’s 
disease for a number of years ? Can they 
get life insurance ? 

Dr. Kaplan: I would think so. I know 
an ophthalmologist who had this dis- 
ease. He has never had any real trouble 
that I know of, and he is the father of 
a couple of children. 

Dr. Rosemberg: At what age does 

one usually exhibit such icterus ? 

Dr. Kaplan: Usually in young people, 
the jaundice is noted after an infection 
in early life. The differential diagnosis 
must be established at that time. 

Dr. Jacobs: Do patients with the 

Dubin-Johnson syndrome do just as well 
as Gilbert people? 

Dr. Kaplan: Not really; they have a 
few more complaints and I don’t know 
whether it is the toxicity of the direct 
bilirubin. Incidentally, there are reports 
that small doses of phenobarbital admin- 
istered orally will cause a dramatic fall 
in severe unconjugated hyperbilirubi- 
nemia in children. 

Dr. Jacobs: Dr. Baxter, what instruc- 
tions were given to this boy and his 
family on discharge? 

Dr. Baxter: They were told that he 
has jaundice which is not serious and 
was likely to have it if he experienced 
some stress or unusual activity, or drank 
alcohol. If in the future he ran across 
a physician who said “Oh you are jaun- 
diced,” he should let that physician 
know that he had a knowledge of his 
diagnosis of Gilbert’s disease lest there 
be a second unwarranted diagnosis of 
“hepatitis”. 

Editor’s Note: “All seems infected 

that the infected spy. As all looks yellow 
to the jaundiced eye” — so wrote Alex- 
ander Pope in his “Essay on Criticism”. 
But how is the practitioner to be sure 


256 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Touro Infirmary 


that the healthy young man without any 
sign of hemolysis or of liver disease 
really has Gilbert’s syndrome as the 
cause of his high blood levels of indirect 
bilirubin? Particularly if the practition- 
er would avoid liver biopsy? There is 
a low-calorie approach. Sherlock and 
Owens fed a 400 calorie diet to normal 
subjects, persons with the Gilbert syn- 
drome and to patients with hepatic dys- 
function or with hemolytic disorders. 
They observed that the patients had no 


significant elevation of bilirubin levels, 
the normal subjects had a distinct in- 
crease in such levels and that almost all 
of their persons with the Gilbert syn- 
drome showed a rise in unconjugated 
bilirubin levels by more than 100 per- 
cent of pre-testing situation.^ While a 
bit inconvenient to the one so tested, this 
method seems most rewarding. 

Reference 

1. Sherlock S, Owens D : Diagnosis of Gilbert’s syn- 
drome: Role of reduced caloric intake test. Br Med J 
3:559-663, 1973 



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July, 1974— Vol. 126, No. 7 


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258 


J. Louisiana State M. Soc. 


itoria. 


Amendatory Patchwork or Repeal 


AMA President, Russell Roth, MD, 
testifying before the Senate Finance 
Subcommittee on Health, said 13 state 
medical societies have formally declared 
for repeal of the PSRO law and that 29 
societies support a policy of amendment 
and/or repeal, (as of May 7, 1974). Dr. 
Roth said “The best efforts of the legis- 
lators involved, the staff of the Senate 
Finance Committee, the staff of the 
PSRO administrative office in HEW, 
and physicians from AMA, from assort- 
ed state medical societies and specialty 
medical organizations, have not succeed- 
ed in creating in the profession the cli- 
mate of acceptance and cooperation 
essential to success. The fault does not 
lie with the sincerity or intensity of the 
effort to cooperate, it lies with the basic 
ineptitudes of the statute.’’ 

“It has been seriously proposed,” he 
said, “that because of the bad start on 
PSRO it may be best to fall back, re- 
group, and start over again. The offi- 
cial AMA position is that repeal may 
need to be considered if amendatory 
patchwork is unacceptable.” 

Dr. W. Charles Miller, New Orleans, 
AMA delegate, reporting to the House 
of Delegates of the Louisiana State Medi- 
cal Society said “It is my belief that in 
the (1974) June meeting in Chicago, 
the House will vote for all-out repeal 
of PSRO as presently presented.” It 
should be noted with some pride that 
our Louisiana delegates, along with Dr. 
James Stewart, our immediate past pres- 
ident, and Dr. Ashton Thomas and his 
staff, have been the spearhead in a1> 
tempts to change the official position of 
the Board of Trustees of AMA in its 
“amendatory patchwork”. Bad, un- 
workable legislation cannot be made 
acceptable with patchwork ; and out- 
right repeal is their mission. 


Basically the concept of “improving 
the quality of health care delivery” with 
an underlying need to control cost is 
desirous, and is accomplishable, but not 
by PSRO. It has been pointed out many 
times that the “control of costs” concepts 
built into the PSRO, would in the final 
analysis, cost millions more than could 
be saved. Quality care now assured by 
skilled independent medical judgments, 
would be replaced by a system of norms, 
eventually leading to a hysteria of “cook- 
book” judgments. Patchwork therefore 
cannot change the ineptitudes. 

Even the underlying intent of the law, 
ie, costs, missed the economic principles 
involved. The vast majority of econo- 
mists and financial writers have over the 
past decade pointed a guilty finger to- 
ward Congress for the underlying rea- 
sons of spiraling costs not only in health 
costs, but in all United States inflation. 
For years it has been recognized that un- 
balanced budgets, open-end give away 
programs, subsidies, and, the overall 
fiscal irresponsibility of Congress would 
surely lead us down the path we are 
now on. Medical costs, as a part of the 
total problems cannot be controlled by 
the implementation of an act which on 
its face is vastly expensive, fiscally irre- 
sponsible, and cannot recoup what it ex- 
pends — its purpose. 

Rep. Jerry Pettis (R. California), a 
member of the Ways and Means Com- 
mittee said recently his colleagues 
should consider some of the end prod- 
ucts of foreign national health systems. 
He cited such cases as Sweden whose 
per capita health costs increased by 614 
percent from 1950 to 1966 compared 
with 174 percent in the United States. 
Since 1960, medical costs in Sweden 
have increased almost 900 percent. In 


July, 1974— Vol. 126, No. 7 


261 


EDITORIAL 


West Germany, there is a serious mal- 
distribution of medical personnel; in 
Norway, a shortage of practitioners; in 
Canada, much higher hospital rates with 
longer stays than in the United States. 
Rep. Pettis said “Certainly there is a 
clear warning in these facts to all of us 
that we should not abandon the strengths 
of the American system for the type of 
health delivery system which has been 
developed in some other country.” These 
astute comments certainly apply to 
PSRO as well. 

Senator Wallace Bennett, (R. Utah), 
during the two day hearing on the work- 
ability of the PSRO statute said “I won’t 
live long enough to see repeal of PSRO.” 
This may be correct if the AMA Board 
of Trustees official position remains un- 
changed; however, if the Chicago dele- 
gates defeat “patchwork” with a re- 
sounding vote of “outright repeal” as 


the official position then Senator Ben- 
nett, will lose one of his principal sup- 
ports — the AMA Board of Trustees. 

A discussion of PSRO cannot be con- 
cluded without expressing our support 
and best wishes for Dr. James Stewart 
in his quest for a position on the Board 
of Trustees. 

By publication time, the House of 
Delegates will have decided the issue of 
their official position; but regardless, 
our direction should remain unchanged, 
ie, to Congress and eventual repeal. The 
state societies already committed to out- 
right repeal have within their collective 
powers enough pens to convince Con- 
gress that PSRO is a bad trip. Has your 
senator or congressman heard from you ? 
As has been recently said, if our direc- 
tion remains unchanged, we will even- 
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J. Louisiana State M. Soc. 




Or g anization ^ecti on 


The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


LSMS MEETING NOTICE 

A meeting af the Executive Committee of the 
Louisiana State Medical Society will be held on 
Thursday, October 24, 1974, beginning at 9:00 
a.m., at the Society headquarters. 


LETTER OF 83 IOWA PHYSICIANS 

PROTESTS “ABORTION ON DEMAND” 

Following is the text of a letter protesting the 
possibility that “abortion on demand” might be- 
come policy at hospitals in Cedar Rapids, Iowa: 

On December 13, 1973, a group of physicians 
met to discuss the necessity for reaffirmation of 
our dedication to protect human life. We feel 
that all people who go into the medical and allied 
fields, whether they be physicians or nurses or 
hospital administrators or hospital employees, 
have become involved and are dedicated to some 
feeling of intrinsic worth in human life. We 
further feel that it is our duty and obligation to 
speak out and make our position known when 
events threaten human life. 

For these reasons, we would like to state that 
we are opposed to any attempt to establish abor- 
tion on demand as a matter of policy in the Cedar 
Rapids area, and in particular in our hospitals. 
We take this stand with the following points defi- 
nitely in mind: 

1. First and foremost, that human Life does 
have intrinsic worth, and it is necessary for us 
to protect and defend and nurture that life. 

2. The history of good medical practice is 
such that surgical procedures are proposed and 
carried out when there is an abnormal physiologic 
or pathologic condition requiring remedy. Abor- 
tion on demand means deliberate destruction of 
living human tissue^ and indeed human life, with 
no demonstrable pathology. This is anathema to 
the traditions of medicine. 

3. The proposition that a woman has the sole 
right to say what happens within her body and 
therefore can destroy living tissue is primarily a 
political-social proposition and has no place in 
dictating good medical practice. 

4. Those who would propose abortion as a 
population control measure, or as some have 
stated, as an extension of a miscalculation of 
contraceptive efforts, again must answer the 
charge of deliberate destruction of human life for 
sociological reasons and not on the basis of good 
medical practice. 


5. The question of the legal right of people 
to expect this “service” in every community, par- 
ticularly in a community where hospitals have 
taken federal money and are therefore obligated 
to allow abortion on demand, has no' basis in 
law. 

The Health Programs Extension Act of 1973 
specifically states that the receipt of any funds 
or loan guarantees under the Public Health Ser- 
vices Act, the Community Mental Health Centers 
Act, or the Developmental Disabilities Services 
and Facilities Construction Act “by an individual 
or entity” does not require “such entity to . . . 
make its facilities available for the performance 
of any sterilization procedure or abortion if . . . 
prohibited by the entity on the basis of religious 
beliefs or moral convictions.” 

For further clarification, see the December 3, 
1973, AM News, which reports the resolution of 
a case based on that ruling in favor of the hos- 
pital, which refused to enter into this type of 
practice. 

For the above reasons, therefore, we wish to 
reiterate that we are opposed to wholesale abor- 
tion on demand as a matter of policy in our 
hospitals. 

There are other reasons for which we oppose 
abortion. In our own community, in which all 
physicians have been free to, and have taken the 
opportunity to, practice to some degree in both 
hospitals and therefore have a very unique med- 
ical community, this is potentially the most di- 
visive issue which we have faced. We would like 
very much to avoid that kind of division of our 
medical community. 

We have been called “an island” which does 
not offer abortion services. We feel that this is 
not in any way a bad sort of island on which to 
live. Those who demand and seek abortion ser- 
vices should be made aware that we feel the 
Cedar Rapids community is a fine medical com- 
munity, and should not be involved in abortion 
on demand. 

John P. Jacobs, MD 

[The letter is also signed by 72 other physicians. 
This is followed by an addendum.] 

The undersigned physicians, while in basic 
agreement that abortion on demand should not 
be a matter of policy for this community, and 
therefore signify their basic agreement by their 


July, 1974— Vol. 126, No. 7 


263 


ORGANIZATION SECTION 


A powerful lot of people 
have been saving at 
Eureka since 1 884 



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110 Belle Chasse Hwy. 

West Bank Division 
EUREKA HOMESTEAD SOCIETY 


signature, wish to emphasize that it is not their 
intention to interfere with what has been trg-di- 
tionally recognized as therapeutic indications for 
abortion. (While not so specifically stated, the 
original letter does not directly interfere with 
this either.) 

[Signed by 10 additional physicians] 

Members of the Louisiana State Medical So- 
ciety might wish to simulate the actions of the 
83 Iowa physicians. 


NARRATIVE SUMMARY OF EXECUTIVE 
COMMITTEE MEETING 

LOUISIANA STATE MEDICAL SOCIETY 
May 30, 1974 

After the invocation given by Dr. Thomas 
Gladney, the order of business was changed for 
the agenda to allow Dr. Terence Beven and Mr. 
Mike Crow to return to the Legislature where a 
hearing before the Health and Welfare Commit- 
tee was to be held. These two gentlemen in- 
formed the Executive Committee of proposed 
amendments to a chiropractic bill that was to be 
discussed by the Health Committee and on which 
action was to be taken. The policy of the House 
of Delegates was to be carried out by objecting 
vigorously to any chiropractic bill. In the opinion 
of the Legislative Council it seemed probable that 
the Health Committee would pass a chiropractic 
licensing bill, then they were to insert the pro- 
posed amendments which would call for consid- 
erably higher educational qualifications and set- 
ting up of a Chiropractic Board, which could 
contain two physicians appointed by the Gov- 
ernor. 

To qualify, an applicant must be 21 years of 
age; 

A citizen of the United States; 

Of good moral character; 

A high school graduate; 

Has completed at least sixty hours of course 
work at a college or university of liberal arts 
and/or science, which at the time of attendance 
thereof, was fully accredited by a nationally 
recognized accrediting agency; 

Has graduated from a chiropractic school or 
college, which at the time of attendance thereof 
was accredited by the Association of Chiropractic 
Colleges or Council on Chiropractic Education or 
their successors and the Board, and which was 
based on four-thousand resident classroom hours; 

Has passed an examination by the Board in the 
following subjects: 

1. Anatomy, 2. Physiology, 3. Hygiene, 4. Nu- 
trition, 5. Pathology, 6. Symptomatology, 7. 
Chemistry, 8. Principles and Practices of Chiro- 
practic, 9. X-ray procedure, interpretation and 
the effect of X-ray on the human body, 10. Bac- 
teriology, 11. Public Health including communi- 

J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


cable and contagious diseases, 12. Neurology, 

13. Physical Diagnosis. 

The Board shall grade all examinations. Reci- 
procity will only be allowed (without examina- 
tion) if the chiropractors comply with the same 
or equivalent requirements as demanded in Lou- 
isiana and are licensed by the other states. 

May only sign certificates that pertain to chiro- 
practic, but not certificates of birth, deaths, etc. 

Suspension or revocation of licenses after a 
hearing and for the following cause: 

1. Conviction of a crime. 

2. Fraud, deceit or perjury in obtaining a di- 
ploma or certificate of licensure. 

3. Habitual drunkenness. 

4. Habitual use of morphine, opium, cocaine 
or other drugs having effect. 

5. Efforts to deceive or defraud the public. 

6. Efforts to obtain payment for chiropractic 
services by fraud, deceit or perjury. 

7. Incompetency, gross negligence, or gross 
misconduct in professional activities. 

8. Violation of provisions of this Chapter re- 
lating to the use of X-ray, medicine and pro- 
cedure. 

9. Violation of federal, state or municipal laws 
or regulations relative to contagious and infec- 
tious diseases or other public health matters. 

10. Engaging in the practice of the healing art 
beyond the scope of chiropractic practice as de- 
fined in this Chapter. 

11. Professional association with an unlicensed 
practitioner which in any way furthers or pro- 
motes the unlicensed practice of chiropractic. 

12. Holding out to the public the abilities of 
curing a manifestly incurable disease or guar- 
anteeing any professional service. 

13. Prescribing, dispensing or administering 
any medicine or drugs. 

14. Solicitation of professional patronage by 
advertising or any other means whatsoever other 
than by conservative announcements of entry 
into, or change of location of practice and/or 
association, professional business cards, and com- 
mercial or professional directory listings which 
notices, cards and listings shall be limited to his 
name, specialties, if any, addresses and telephone 
numbers of the practitioners involved and a brief 
statement of the purpose of any such notice or 
listing. 

15. For using the title Doctor, Dr., its equiva- 
lent without using the term chiropractor, or its 
equivalent as a suffix or in connection therewith 
under such circumstances as to induce the belief 
that the practitioner is entitled to practice any 
portion of the healing arts other than chiropractic 
as defined herein. 

16. Nothing in this part shall be construed to 
prevent a licensed practitioner from mailing edu- 
cational material to his patients or the dissemina- 


tion of educational material, approved by the 
Board, by Chiropractic societies or associations. 

Grandfather Clause 

Applicant who has practiced eight years in 
Louisiana at time of passage of Act shall be 
granted a license without examination, provided 
he has not failed a board examination, or had his 
license revoked in another state prior to practic- 
ing in Louisiana. In the event of a failure of 
examination or revocation of license, he shall be 
given an examination in X-ray procedure, phys- 
ical diagnosis and public health, including com- 
municable and contagious diseases. 

Applicants practicing in Louisiana less than 
eight years and more than two shall be given the 
examination in X-ray procedure, physical diag- 
nosis and public health, including communicable 
and contagious diseases. 

Applicants practicing in Louisiana less than 
two years must take the large examination of 
thirteen components except paragraph 5 of Sec- 
tion 2805. Applicants described in paragraph 5 
who have passed the National Chiropractic Board 
Examination may take the lesser examination in 
lieu of the thirteen component examinations. 

Requirement in paragraph 5 of Section 2803 
is waived for any Louisiana resident who at the 
effective date of this Chapter is attending a 
chiropractic school or college, accredited by the 
Association of Chiropractic Colleges or the Coun- 
cil on Chiropractic Education or their successors 
and the Board. 

X-ray procedures shall not include radio- 
therapy fluoroscopy or any other form of ioniz- 
ing radiation, except X-ray which may be used 
only as follows: 

1. X-ray only used for chiropractic analysis. 

2. Wombs of pregnant females shall not be 
exposed to X-ray radiation. 

3. X-ray film shall not exceed 14x36 inches 
in size. 

This is to great extent the amended Bill No. 
712 by Messrs. Stephenson and Breaux. 

The Medical Technicians Licensure Bill, on 
which the Executive Committee had previously 
expressed opposition, was brought up for recon- 
sideration. Dr. Terence Beven was asked ques- 
tions concerning same and the Executive Com- 
mittee again voted their opposition to this bill. 

Mr. Friedlund of Johnson and Higgins then 
made a progress report which is well covered in 
the regular minutes. 

The President’s report needs no additional 
comment. 

In the Secretary-Treasurer’s report it might be 
stated that the LSMS Active Membership in- 
creased 128 over that of last year at this partic- 
ular time. AMA increased 77 over the same 
period last year. 

Mr. Paul Perret gave a report on the activities 


July, 1974 — Vol. 126, No. 7 


265 


ORGANIZATION SECTION 


in Dr. James H. Stewart’s behalf in our effort 
to have Jim elected to the AM A Board of 
Trustees. 

Miss Annie Mae Shoemaker was recommended 
by the Executive Committee for honorary mem- 
bership. Miss Shoemaker is terminating thirty- 
nine years of service to the LSMS and is almost 
indispensable. The Executive Committee wishes 
her only the best during her coming retirement. 
This will be sent to the House of Delegates for 
final action. 

Several recommendations of committees which 
were returned to committees for clarification 
were approved by the Executive Committee to 
be reported to the House of Delegates. 

Commendations were expressed to Drs. Moss 
and Garber and the entire Calcasieu Parish Med- 
ical Society for the arrangements at the last 
Annual Meeting. 

Deletion of the word “mandatory” in the third 
recommendation of the Committee on Medical 
Aspects of Automotive Safety was requested. 
Chairman T. E. Banks has been so notified. 

Mrs. Ralph McDonough and Mrs. William 
Cloyd were invited to and did attend our meeting. 
Both reported on Auxiliary activities and their 
interest in what LSMS priorities might be. 

An old nemesis cropped up at the meeting 
when Dr. Kavanagh presented a letter from Ms. 
Stuck regarding a class action suit. She is charg- 
ing racial discrimination in hospital admissions, 
admission being disproportionate among black 
and whites, records, assignment of beds in a seg- 
regated manner, refusal to admit patients who 
are not already patients of physicians with staff 
privileges, refusal to admit patients who do not 
have cash deposits or insurance coverage, failure 
to actively recruit black physicians with staff 
privileges and failure to take action to correct 
community attitudes toward segregation in hos- 
pitals. 

Hotel Dieu was given until 31 May 1974 to 
answer questions of Ms. Stuck which is an im- 
possibility. 

Hotel Dieu has asked the LSMS to investigate 
this serious problem, particularly the legality of 
the Director’s Office for Civil Rights in demand- 
ing privileged information. 

In 1967 the LSMS adopted Resolutions #113 
and #113 A and revocation of the demands when 
Mr. John Gardner was Secretary of H.E.W. 

At that time in 1967 the Regional Director for 
H.E.W. was demanding that hospitals furnish 
percentages of colored and white patients admit- 
ted by each staff member of each hospital. 

The House of Delegates in 1967 felt that this 
type of action was not provided in the law and 
regarded it as interference of the physician in 
his right to practice medicine, or the manner in 
which medical services are provided. 


They resolved that the LSMS disapprove such 
action and that our protest be sent to responsible 
directors of H.E.W. and to members of Congress. 

The Secretary has been instructed to write a 
letter of protest once again to the proper authori- 
ties and to members of Congress. 

The question of supplying the whole record to 
Blue Cross, which is being demanded of Our Lady 
of the Sea Hospital in Galliano, was discussed 
to considerable extent. Dr. F. Michael Smith, our 
President-Elect, was very familiar with the situa- 
tion and volunteered to represent the LSMS at 
a meeting with Blue Cross and members of the 
Staff and governing body of Our Lady of the 
Sea Hospital and he was authorized to represent 
the LSMS. 

Dr. Riggs asked for assistance from those at- 
tending the Annual Meeting of the AMA in 
Chicago in covering the Reference Committees. 
This will be further discussed at the Monday 
morning breakfast. Physicians were also asked to 
write their friends who might be delegates in Dr. 
James Stewart’s behalf as a candidate for the 
Board of Trustees to the AMA. 

Communications containing constructive criti- 
cism of some of the shortcomings of our Annual 
Meeting were read and discussed. 

Dr. St. Martin elaborated most succinctly on 
the activities of HEAL, particularly concern- 
ing a new building at Charity Hospital and 
renovation of the old and a classroom and science 
building at L.S.U. 

Members of the Executive Committee were not 
in accord with a program proposed by the Louisi- 
ana Hospital Association on Assessment of Qual- 
ity in Medical Care Consultations with a grant 
from the Louisiana Regional Medical Program. 
The Secretary was instructed to write a letter to 
both of these organizations expressing our oppo- 
sition. 

Congratulatory letters referable to the services 
rendered in the Legislature by Mr. Percy Landry 
from the Speaker of the House, Rep. E. L. Henry, 
and the Presiding Officer of the Senate, Lt. Gov. 
James Fitzmorris, Jr., were read. 

Due to the unfortunate death of Dr. B. B. 
Weinstein, who was Chairman of the Ad Hoc 
Committee on Medical History and Exhibits to 
formulate plans for the bicentennial celebration, 
it was necessary to seek other sources in order 
to participate. Dr. Harold Cummins of Tulane 
was suggested as a very logical contact to consult 
in this regard. 

Subject to the approval of our Legal Counsel, 
LAMPAC was given the go-ahead signal in fund- 
ing for activities against PSRO. Radio and TV 
spots at prime time will be offered in opposition 
to PSRO. Dr. Terence Beven was elected as rep- 
resentative of the LSMS on the LAMPAC Board 
for the year 1974-75. 


266 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


The names of three physicians were chosen to 
be submitted to Governor Edwards as representa- 
tives of the LSMS on the HEAL Board, namely: 
Dr. Arthur G. Kleinschmidt, Jr., Dr. F. Michael 
Smith and Dr. Sam L. Gill. 

A possible appointee from the LSMS to the 
editorial board in health crisis articles was re- 
fen-ed to the Public Relations Committee with 
the P.R. director to report back to the Executive 
Committee. 

The Legislative Council was asked to support 
H.B. 246, which is a bill relative to maintaining 
adequate school nurses in the community. 

The minutes, as printed and forwarded to the 
entire Executive Committee were very accurate 
and so full and narrative that they needed little 
or no expansion except on the chiropractic situa- 
tion and the letter of demands by the Director 
for the Office of Civil Rights, Ms. Stuck. 


USING AMINOBENZOIC ACID-TYPE 
SUNSCREEN MAKES FOR TANNING 
WITHOUT BURNING 

The Labor Day holiday will witness the final 
“skin roast” of the season, as many families head 
for the parks and the beaches and a long weekend 
out of doors in the late summer sunshine. 

A sizeable number will return to office and 
classroom suffering from sunburn. 

A scientific paper published in the Archives of 
Dermatology, a professional journal of the Amer- 
ican Medical Association, reported on new studies 
which further confirm that a proper sunscreen 
preparation applied to the skin will permit tan- 
ning without burning. 

And even more important, a good sunscreen 
will prevent the serious tissue damage from sun- 
burn which underlies aging changes and pre- 
cancerous and cancerous skin problems, said the 
article. Authors are Andrzej Langner, MD and 
Albert M. Kligman, MD, both of the University 
of Pennsylvania School of Medicine, Philadelphia. 

The product tested is known by the chemical 
name of aminobenzoic acid. It is packaged com- 
mercially under several different trade names. 

“We believe that sun-sensitive subjects should 
apply sunscreens as part of their daily toilet,” 
the authors recommend. 

Solutions of aminobenzoic acid in alcohol and 
water, with light perfumes added, are now avail- 
able, they said. 

The studies still are continuing, but the authors 
state definitely that: 

“It is possible to produce a deep tan through 
aminobenzoic acid-treated skin in the absence of 
visible sunburn.” The tanning will be without 
any evident damage to the skin. 

The experiment was conducted by treating 
sections of untanned skin on the backs of volun- 
teers with the preparation, subjecting the area 


to heavy doses of sunlight-type rays from sun- 
lamps, and then comparing the results on the 
treated skin areas with those on the untreated 
skin adjoining. The untreated skin showed 
uncomfortable bums. The treated skin escaped 
unharmed, but showed a marked tan. 


YALE RESEARCH GROUP URGES TESTING 
OF NEWBORNS FOR SICKLE CELL TRAIT 

Routine screening of blood samples from umbil- 
ical cords of infants immediately after birth to 
detect sickle cell diseases is recommended by a 
medical research team from Yale University 
School of Medicine in a report in the January 28, 
1974 issue of the Journal of the American Medi- 
cal Association. 

Sickle cell anemia occurs with an estimated 
frequency of 1 in 600 births among black Amer- 
icans. 

In a research study conducted at Yale-New 
Haven Hospital, 8 of 756 black and Puerto 
Rican newborns screened during one year had 
major sickling blood problems, the doctors report. 

“Identification of affected infants should per- 
mit anticipation and, hopefully, prevention of 
major catastrophic complications that contribute 
to the high mortality for sickle cell diseases in the 
first years of life.” 

The tests cost only $3.50 each, taking less than 
two hours to complete, requiring simple and in- 
expensive equipment and can be performed by 
individuals with little technical training. 

“Early recognition of sickle cell anemia is a 
valid medical goal. There is as yet no specific 
therapy for sickle cell anemia, but many of the 
complications, including life-threatening episodes 
of overwhelming infection crisis, can be mini- 
mized by early medical intervention. 

“Diagnosis at birth permits utilization of the 
first few months of life for parental education 
and counseling and for ensuring that direct access 
to prompt and competent medical and social re- 
sources is provided. Genetic counseling of the 
family concerning future pregnancies can also be 
given.” 

The research study was conducted by Howard 
A. Pearson, MD, Richard T. O’Brien, MD, Sue 
McIntosh, MD, Gregg T. Aspnes, MD, and Mei- 
Mei Yang, MS. 


AMA WARNS AGAINST SIPHONING 
OF GASOLINE 

Warning! Siphoning gasoline may be danger- 
ous to your health! It might even kill you! 

With the advent of gasoline shortages, motor- 
ists are resorting to any number of improvisa- 
tions to keep their wheels moving. Siphoning of 
fuel may be one of them. 

If you must transfer fuel by siphon, use a 
device that is self-priming — do not attempt to 


July, 1974— Vol. 126, No. 7 


267 


ORGANIZATION SECTION 


draw a vacuum by mouth, warns Asher J. Finkel, 
MD, director of the Division of Scientific Activi- 
ties of the American Medical Association. 

Gasoline swallowed or inhaled can cause severe 
health problems; in extreme cases, motor fuel 
can cause death, if the amount consumed is suf- 
ficiently large. Dr. Finkel said. 

“Above all, have an adequate means of venti- 
lation, not only to forestall a possible fire or ex- 
plosion, but also to prevent asphyxiation and/or 
intoxication by aromatic hydrocarbon components 
of gasoline,” he said. 

The greatest danger in swallowing a signifi- 
cant amount of gasoline is that the fuel may 
reach the lungs, either by inhalation or via the 
blood stream. The effect will be a form of pneu- 
monia and possible lung damage. 

First aid is limited when gasoline is swallowed 
or inhaled. Oxygen may help relieve breathing 
distress. DO NOT induce vomiting or drink large 
quantities of water. If breathing problems de- 
velop, it is important to get medical attention 
promptly. 

Inexpensive devices are on the market — a 
length of tubing with attached squeeze bulb — 
that take the worry out of siphoning. So if you 
are forced to borrow from one tank to supply 
another, use one of these gadgets, not your 
mouth ! 


HOME POISONS 

Upstairs, downstairs, all through the house are 
deadly poisons, ready for the taking. 

Catherine de Medici hid deadly poisons behind 
a secret panel in her boudoir. The American Med- 
ical Association points out that your supply of 
potential poisons are not so well hidden. 

Seemingly harmless household items, items 
which cause half a million accidental poisonings 
in our nation each year, are probably stored in 
every room of your house. Before someone finds 
them accidentally, with serious results, look for 
these items: 

• Kitchen killers may include household 
chemicals such as detergents, ammonia, silver and 
brass polishes, disinfectants, room deodorants 
and insect poisons. They may be under the kitchen 
sink in easy reach of children. 

• Medicines cause most accidental poisonings 
in children, and aspirin leads the pack. Many 
medicines today, fortunately, come with safety 
tops, difficult for small children to remove. Cos- 
metics, deodorants, shaving lotion and unlabeled 
medicine can poison adults who take them in the 
dark without reading the labels. 

• The home workshop has its dangers, too. 
Children are curious enough to drink paints, lac- 
quers, varnishes and turpentine, especially if you 
leave these chemicals in empty soft drink bottles. 


• Garden aids, such as insect sprays, weed 
killers and fertilizers may benefit your plants, 
but they can kill children. Store garden chem- 
icals out of reach of children. When applying, 
keep preparations away from eyes, nose, mouth 
and skin. 

• In the bedroom, never leave cosmetics and 
pills on tabletops or in low drawers where chil- 
dren can find them. Mothballs are a hazard if 
you store winter clothes in a low chest that chil- 
dren can reach. 

Some final precautions — label everything, 
keep medicine in a locked cabinet, never store 
chemicals in food or beverage containers or on 
food shelves, date medicines and discard old 
drugs, use only prescriptions ordered for you by 
a physician, do not contaminate food or utensils 
with insect sprays, aerosols, rat poisons, weed 
killers or cleaning agents, and, keep potential 
poisons out of children’s reach. 

The New Orleans Poison Control .Center at 
Charity Hospital is one of the best. For informa- 
tion regarding any type of poisoning call 524- 
3617. 



WANTED 

An Internist and a Family Practice Physician by 

nine man group in 60,000 population community 
in Central Louisiana. Excellent new hospital facili- 
ties. Group consists of general surgery, Ob-Gyn, 
family practice and internal medicine. Salary for 
the first year negotiable, partnership to follow. 
Liberal fringe benefits. Sub-specialty in cardiology 
or pulmonary disease useful but not necessary. 

Contact T. W. Davis, M.D. or W. H. Brown, M.D., 
Area Code 318, Phone 445-4513, 830 DeSoto 
Street, Alexandria, Louisiana 71301. 


268 


J. Louisiana State M. Soc. 


WjluJ f}^ Sect. 


ion 


CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every month 


Calcasieu 

Fourth Tuesday of every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday of every month 

Baton Rouge 

Jackson- Lincoln- Union 

Third Tuesday of every month 
except summer months 

Jetterson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every ether month 

Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Second Tuesday of every month 

Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

Independence 

Terrebonne 

Third Monday of every month 

Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday of every month 


SEPTEMBER AND OCTOBER 1973 LSMS 
JOURNALS NEEDED 

The LSMS has exhausted its supply of the Sep- 
tember and October 1973 issues of The Journal 
of the Louisiana State Medical Society. Members 
who have copies of these issues, and no longer 
have need for them, are urged to return them to 
the Journal office. 


HIGH SCHOOL RESEARCHERS WIN 
AM A AWARDS 

John Randall King of Ruston, Louisiana has 
received the American Medical Association’s 
Award of Merit in recognition of scientific 
achievement. 

John, a 17-year-old student at Ruston High 
School, was a participant in the 25th Interna- 
tional Science Engineering Fair in South Bend, 
Indiana, May 5-11. His award-winning project 
demonstrated the “Relationship of Various Sug- 
ars and Hormones on Induced Hypoglycemia.” 
John has participated in regional science fairs for 
the past two years. He is a member of the high 
school band, science club, and the Junior Acad- 
emy of Sciences. He was named as a Boy’s State 
representative and is a member of the National 
Honor Society. John plans a career in veterinary 
medicine or medical research. 

Other awards of merit were presented to Tricia 
Kosco for “A New Concept in Flame Retardance 
of Fabrics,” Albert J. Allen for the investigation 
of “The Effects of Various Agents on the Guinea- 


pig Ileum,” Karleen E. Leuth for her project, 
“Use of Reserpine and Cystine on Red Blood.” 

Plaques were presented to each student by 
Donald E. Wood, MD, member of the AMA Board 
of Trustees, at the Health Awards Banquet held 
in conjunction with the International Science and 
Engineering Fair. 

Speaker for the evening was F. Story Mus- 
grave, physician-astronaut from NASA, who 
stressed the need for interdisciplinary cooperation 
between health researchers and other scientific 
investigators. 

The Health Awards Banquet is an annual event, 
hosted by the AMA in conjunction with the 
American Dental Association, the American 
Pharmaceutical Association and the American 
Veterinary Medical Association in a continuing 
effort to encourage the scientific development — 
and recognize the scientific achievement — of 
young people. 


COURSE ANNOUNCEMENT 

Under the aegis of the American Society for 
Gastrointestinal Endoscopy, a postgraduate course 
on gastrointestinal endoscopy will be offered, 
emphasizing technics and applications, on Thurs- 
day, November 7, and Friday, November 8, 1974, 
in New Orleans, Louisiana, at Monroe Hall audi- 
torium of the Department of Education of the 
Ochsner Foundation, with a faculty selected from 
Louisiana State University Medical Center, Tu- 
lane University Medical Center and the Ochsner 
Foundation, with additional visiting authoritative 


July, 1974— Vol. 126, No. 7 


269 


MEDICAL NEWS 


faculty members from the continental United 
States and from Europe. 

For further information contact Dr. Gordon 
McHardy, 3638 Saint Charles Avenue, New Or- 
leans, Louisiana 70115. 


SMA TO HOLD 1974 MEETING 
IN ATLANTA 

Following on the heels of its most highly suc- 
cessful scientific meeting in many years, the 
Southern Medical Association (SMA) announced 
recently the 1974 Annual Scientific Meeting will 
be held in Atlanta, November 17-20. 

More than 4,000 physicians and paramedical 
personnel gathered in San Antonio for the 67th 
SMA meeting which presented more than 300 
speakers in all disciplines of medicine. 

The newly elected president of SMA, Dr. 
George J. Carroll, of Suffolk, Va., said the meet- 
ing in Atlanta would be planned to surpass even 
the San Antonio meeting, which was outstanding 
with its coverage of all medical specialties. “We 
expect the meeting in Atlanta to break all pre- 
vious records,” Dr. Carroll said. “Our other At- 
lanta meetings have been extremely well attend- 
ed, due in great part to the fine medical facilities 
there, and the easy accessibility of the city. 

“Teaching demonstrations with live patients 


actually being treated were an innovation at the 
San Antonio meeting, and will be expanded for 
the 1974 meeting. They met with great success 
this year, and the interest shown in them was 
beyond our expectations,” Dr. Carroll continued. 
“The postgraduate courses, also new this year, 
were equally well received and will be con- 
tinued.” 

Dr. Carroll stated that the 1973 scientific 
exhibits of the physicians were singled out for 
special commendation because of their excellence. 

Other officers elected at the recent SMA meet^ 
ing are: Dr. Andrew M. Moore, Lexington, Ky., 
president-elect; Dr. G. Gordon McHardy, New 
Orleans, La., first vice president; and Dr. John 
J. Hinchey, San Antonio, Tex., second vice presi- 
dent. Dr. G. Thomas Jansen, Little Rock, Ark., 
was elected chairman of the council, and Dr. 
Andrew F. Giesen, Fort Walton, Fla., vice chair- 
man. 


TRAVEL HEALTH TIPS 

With the approach of the summer vacation 
travel season, the family should once again re- 
member that illness can dampen or ruin your 
summer vacation. 

That long awaited and keenly anticipated trip 



coliseum house 


a private mental 
in answer to a 

A 100 beds 

A complete psychiatric services 


health facility 
special need 

A specialty units 
A fully staffed and equipped 


For information, please contact: 

Malcolm L. Latour, M.D. 

Medical Director 

Coliseum House 
3601 Coliseum Street 
New Orleans, Louisiana 701 15 
504/895-3971 


Charles R. Trufant 

Administrator 


270 


J. Louisiana State M. Soc. 


MEDICAL NEWS 


to the seashore or the mountains can be a com- 
plete dud if you get sick. 

The American Medical Association offers five 
tips that will help you avoid illness and insure 
that your vacation is a period of fun and relaxa- 
tion for all the family. This will help everyone 
get rejuvenated and ready to face another year. 

(1) Depending on where you are going, you 
may need some vaccination shots. Tetanus, cer- 
tainly, for anyone who expects to include some 
out of doors activities. Typhoid, if your journey 
includes areas where the water supply is uncer- 
tain. Ask your doctor about these, and possibly 
other, immunizations. 

(2) Use common sense about your vacation 
diet. Many a family trip has been spoiled by too 
many roadside hamburgers and soft drinks. A 
sound rule while driving cross country is to eat 
lightly. Be cautious about heavy, rich meals, par- 
ticularly if you’re not accustomed to such fare 
at home. 

(3) Know what sort of climate you will en- 
counter at your vacation spot and dress accord- 
ingly. It can get cold in the mountains at night, 
even in mid-summer. Good walking shoes are 
important to the travel wardrobe. 

(4) If you wear glasses, take along an extra 
pair. Or, at least a copy of your prescription. If 
you’re on a regular medication, such as insulin 
for diabetes, make certain of your supply before 
you leave. 

(5) And, finally, don’t overdo it. Almost no 
one other than a trained athlete is ready for 36 
holes of golf or 5 sets of tennis under a broil- 
ing sun. Schedule your vacation to allow daily 
rest periods. Do most of the driving in the morn- 
ing hours and stop for the evening in early or 
mid-aftemoon. 

Your vacation should be a holiday for rest and 
relaxation. It should not be a grind that neces- 
sitates another vacation to rest up from the va- 
cation. 

An important after-thought that won’t bother 
your health but could well affect your emotional 
being — will there most likely be enough gaso- 
line available along your route to get you there 
and back? 


HAROLD CUMMINS AWARD 

Dr. John Jackson, professor of preventive med- 
icine at the University of Mississippi School of 
Medicine, was recently presented the Harold 


Cummins Award in honor of Dr. Cummins, emer- 
itus professor of anatomy at Tulane School of 
Medicine. Dr. Jackson is a native of Kosciusko. 

At the annual meeting of the Tulane Medical 
Alumni Study Club, Dr. Jackson was one of the 
featured lecturers, discussing progress in human 
cytogenetics. 

A graduate of the University of Mississippi, 
he holds the MD from Tulane University, where 
he also taught on the faculty. 

He has studied at the Institute for Medical 
Genetics in Uppsala, Sweden, and two years ago 
took a sabbatical leave from the Medical Center 
to do further specialty research in Hawaii. 

Dr. Jackson’s primary research interests also 
extend to cytogenetics of tumors, hematology 
and the laboratory aspects of homotransplanta- 
tion. 


INTERNAL MEDICINE SPECIALTY 
COLLEGE ELECTS OFFICERS, REGENTS 
AND GOVERNORS 

Robert G. Petersdorf, MD, Professor and Chair- 
man of the Department of Medicine at the Uni- 
versity of Washington, Seattle, has been chosen 
president-elect of the 26,500-member American 
College of Physicians. He will succeed Truman 
G. Schnabel, Jr., MD, Philadelphia, Pa., in 1975 
as top officer of the medical specialty society. 

Elected Vice President at the ACP Annual 
Session on April 4 in New York City was Harri- 
son J. Shull, MD, Nashville, Tenn., Clinical Pro- 
fessor of Medicine at Vanderbilt University 
School of Medicine. 

In another action, the American College of 
Physicians announced the appointment of Rich- 
ard W. Vilter, MD, Professor of Medicine at the 
University of Cincinnati College of Medicine, to 
a three-year term as secretary-general of the or- 
ganization. He succeeds R. Carmichael Tilghman, 
MD, Baltimore, Md. 

Eight physicians were elected to the American 
College of Physicians Board of Regents. They 
were: Maxwell G. Berry, MD, Kansas City, Mo.; 
Edmund B. Flink, MD, Morgantown, W. Va. ; 
John R. Evans, MD, Toronto, Canada; Jack D. 
Meyers, MD, Pittsburgh, Pa.; George W. Pedigo, 
Jr., MD, Louisville, Ky. ; Herbert W. Pohle, MD, 
Milwaukee, Wise.; Ralph R. Tompsett, MD, Dal- 
las, Tex., and Theodore E. Woodward, MD, Balti- 
more, Md. 


July, 1974— Vol. 126, No. 7 


271 


INFORMATION FOR AUTHORS 

Manuscripts should be typewritten, double- 
spaced on firm white paper 8'/2 x I 1 inches with 
adequate margins. This applies to all text elements: 
references, legends, footnotes, etc. Single spaced 
manuscripts and photo copies will not be consid- 
ered. The original and one duplicate copy should 
be submitted. Manuscripts are received with the 
explicit understanding that they are not simulta- 
neously being considered by any other publication. 
Accepted manuscripts become the property of 
THE JOURNAL and may not be published else- 
where without permission from the author and 
THE JOURNAL. Manuscripts are subject to copy 
editing. 

References must be limited to a reasonable num- 
ber. They will be critically examined at the time 
of review and must be kept to a minimum. Personal 
communications and unpublished data should not 
be included. The following minimum data should 
be typed double spaced: names of all authors, 
complete title of article cited (lower case), name 
of journal abbreviated according to Index Medicus, 
volume number, first and last page numbers, and 
year of publication. All references must be cited 
in the text and the list should be arranged in 
order of citation, and not alphabetically. 

Illustrations consist of material which cannot be 
set in type. Photographic material should be sub- 
mitted as high contrast, glossy prints. Drawings 
and graphs must be done professionally in India 
ink on high grade white drawing paper. Omit 
illustrations which do not increase understanding 
of text. Composite figures and figures labeled A, 
B, C, etc., cannot be reproduced adequately in 
column width without loss of detail; therefore, each 
segment must be considered a separate illustration. 
Illustrations must be limited to a reasonable num- 
ber. Four illustrations should be adequate for a 
manuscript of 1 6 to 18 typed pages. Legends 
should be typed on a separate sheet of paper. 
The following information should be typed on a 
gummed label and affixed to the back of each 
illustration: figure number, title of manuscript, 

name of senior author, and arrow indicating top. 

Tables should be self-explanatory and should 
supplement, not duplicate, the text. Tables must 
be numbered consecutively, each must have a 
title, and each should be typed on a separate 
sheet of paper. 

Subheads should be used to provide guidance 
for the reader. This format is flexible but the 
subheads would ordinarily include: Methods and 

Materials, Case Reports, and Discussion. 

Reprint orders will accompany galley proofs 
which are sent for author's corrections. 


Rondomycin 

(methacycline HCI) 


CONTRAINDICATIONS: Hypersensitivity to any of the tetracyciines. 

WARNINGS: Tetracycline usage during tooth development (last half of pregnancy to eight 
years) may cause permanent tooth discoloration (yellow-gray-brown), which is more 
common during long-term use but has occurred after repeated short-term courses. 
Enamel hypoplasia has also been reported. Tetracyclines should not be used in this age 
group unless other drugs are not likely to be ellective or are contraindicated. 
Usage in pregnancy. (See above WARNINGS about use during tooth development.) 

Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de- 
veloping fetus (often related to retardation of skeletal development). Embryotoxicity has 
also been noted in animals treated early in pregnancy. 

Usage in newborns, infants, and children. (See above WARNINGS about use during 
tooth development.) 

All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease 
in fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6 
hours was reversible when drug was discontinued. 

Tetracyclines are present in milk of lactating women taking tetracyclines. 

To avoid excess systemic accumulation and liver toxicity in patients with impaired renal 
function, reduce usual total dosage and, if therapy is prolonged, consider serum level de- 
terminations of drug. The anti-anabolic action of tetracyclines may increase BUN. While 
not a problem in normal renal function, in patients with significantly impaired function, 
higher-tetracycline serum levels may lead to azotemia, hyperphosphatemia, and acidosis. 

Photosensitivity manifested by exaggerated sunburn reaction has occurred with tetra- 
cyclines. Patients apt to be exposed to direct sunlight or ultraviolet light should be so ad- 
vised, and treatment should be discontinued at first evidence of skin erythema. 
PRECAUTIONS: If superinfection occurs due to overgrowth of nonsusceptible organisms, 
including fungi, discontinue antibiotic and.start appropriate therapy. 

In venereal disease, when coexistent syphilis is suspected, perform darkfield exami- 
nation before therapy, and serologically test for syphilis monthly for at least four months. 

Tetracyclines have been shown to depress plasma prothrombin activity: patients on an- 
ticoagulant therapy may require downward adjustment of their anticoagulant dosage. 

In long-term therapy, perform periodic organ system evaluations (including blood, 
renal, hepatic). 

Treat all Group A beta-hemolytic streptococcal infections for at least 10 days. 

Since bacteriostatic drugs may interfere with the bactericidal action of penicillin, avoid 
giving tetracycline with penicillin. 

ADVERSE REACTIONS: Gastrointestinal (oral and parenteral forms): anorexia, nausea, 
vomiting, diarrhea, glossitis, dysphagia, enterocolitis, inflammatory lesions (with monil- 
ial overgrowth) in the anogenital region. 

Skin: maculopapular and erythematous rashes: exfoliative dermatitis (uncommon). Pho- 
tosensitivity is discussed above (See WARNINGS). 

Renal toxicity: rise in BUN, apparently dose related (See WARNINGS) . 

Hypersensitivity: urticaria, angioneurotic edema, anaphylaxis, anaphylactoid purpura, 
pericarditis, exacerbation of systemic lupus erythematosus. 

Bulging fontanels, reported in young infants after full therapeutic dosage, have disap- 
peared rapidly when drug was discontinued. 

Blood: hemolytic anemia, thrombocytopenia, neutropenia, eosinophilia. 

Over prolonged periods, tetracyclines have been reported to produce brown-black mi- 
croscopic discoloration of thyroid glands: no abnormalities of thyroid function studies are 
known to occur. 

USUAL DOSAGE: Adults- 600 mg daily, divided into two or four equally spaced doses. 
More severe infections: an initial dose of 300 mg followed by 150 mg every six hours or 
300 mg every 12 hours. Gonorrhea: In uncomplicated gonorrhea, when penicillin is con- 
traindicated. 'Rondomycin' (methacycline HCI) may be used for treating both males and 
females in the following clinical dosage schedule: 900 mg initially, followed by 300 mg 
q.i.d. for a total of 5.4 grams. 

For treatment of syphilis, when penicillin is contraindicated, a total of 18 to 24 grams of 
■Rondomycin' (methacycline HCI) in equally divided doses over a period of 10-15 days 
should be given. Close follow-up, including laboratory tests, is recommended. 

Eaton Agent pneumonia: 900 mg daily for six days. 

Children- 3 to 6 mg/lb/day divided into two to four equally spaced doses. 

Therapy should be continued for at least 24-48 hours after symptoms and fever have 
subsided. 

Concomitant therapy: Antacids containing aluminum, calcium or magnesium impair ab- 
sorption and are contraindicated. Food and some dairy products also interfere. Give drug 
one hour before or two hours after meals. Pediatric oral dosage forms should not be 
given with milk formulas and should be given at least one hour prior to feeding. 

In patients with renal impairment (see WARNINGS), total dosage should be decreased 
by reducing recommended individual doses or by extending time intervals between 
doses. 

In streptococcal infections, a therapeutic dose should be given for at least 10 days. 
SUPPLIED: 'Rondomycin' (methacycline HCI): 150 mg and 300 mg capsules: syrup con- 
taining 75 mg/5 cc methacycline HCI. 

Before prescribing, consult package circular or latest PDR information. 

Rev. 6/73 

kffi WALLACE PHARMACEUTICALS 
\k§ CRANBURY, NEW JERSEY 08512 


272 


J. Louisiana State M. Soc. 


The Journal 

of the 

Louisiana State Medical Society 


$6.00 Per Annum, $1.00 Per Copy ATir'TTQT' 1 O'?/! Published Monthly 

Vol. 126, No. 8 U Vjr U O i , 1700 Josephine Street, New Orleans, La. 70113 


introduction 


The clinical articles which follow are representative of the 
academic efforts in family medicine which have emerged during 
the last five years at the LSU School of Medicine in New Orleans. 
The Louisiana Chapter of the American Academy of Family Physi- 
cians has been a strong force in this "new” era of family practice. 
Louisiana family doctors have responded enthusiastically to serve 
as teachers in Baton Rouge and Lake Charles. A similar effort at 
the LSU School of Medicine in Shreveport is meeting with equal 
success. 

The content of this issue, while representative, is by no means 
complete. Future issues of the Journal of the Louisiana State Med- 
ical Society will bring more articles to further acquaint you with the 
new breed of "family doctor” of today. 


August, 1974 — Vol. 126, No. 8 


273 


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274 


J. Louisiana State M. Soc. 




Family Physician: 

How Is He Trained in Louisiana? 


• What is a family physician and how do you go about training 
him? These are the questions our medical colleagues ask most. 
The following is an attempt to answer these questions from our 
experience in the Louisiana State University Family Medicine Resi- 
dency Training Program at the Earl K. Long Memorial Hospital 
in Baton Rouge. 


'^HE Family Medicine Residency Train- 
ing Program at the Earl K. Long Hos- 
pital is in its third year of operation. One 
resident graduated in June, 1972. One 
graduated in June, 1973. Our program 
will graduate two residents this year, four 
next year, and then, hopefully, six to eight 
family physicians each year thereafter. 

Primary Objectives 

The residency program in family medi- 
cine at the Earl K. Long Hospital has four 
primary objectives: 

I. To Train a Physician in “Primary 
Care” 

A. This physician will be capable of 
rendering primary care to all members 
of the family, regardless of age or sex, 
for any medical or surgical problem, be 
it organic or emotional. He will be able 
to follow 85 to 90 percent of all patient 
problems to completion without consul- 
tation and act as a medical envoy for the 
remainder into the vast specialty and 
sub-specialty areas. 

II. To Train a Physician in Family 
Medicine 

A. Health maintenance 

1. This physician will be able to 
recognize and counsel the patient, the 
family, and the community in the 
ways and means of preventing dis- 
ease, prolonging life, making life more 
productive and enjoyable, ie, counsel- 

* Dr. Gehringer is the Director, Family Prac- 
tice Residency Training Program, Earl K. Long 
Memorial Hospital, Baton Rouge, Louisiana. 


GERALD R. GEHRINGER, MD* 
Baton Rouge 

ing in smoking, cardiovascular dis- 
eases, pulmonary diseases, cancer, be- 
havioral problems, diet, genetics, im- 
munizations, regular check-ups, prop- 
er dental care, etc. 

B. Continuing Comprehensive Medical 
Care 

1. This physician will be able to uti- 
lize consultants and work with them 
in patient care. He will be a vital part 
of the team at all times, never totally 
relinquishing care of the patient or 
his family. 

2. He will be well trained in conti- 
nuity of care in all areas, ie, chronic 
obstructive lung disease, heart dis- 
ease, cancer, terminal illness, emotion- 
al illness, etc. 

HI. To Train a Physician in Hospital, 
Office, Business and Career Management 

A. The resident will serve on hospital 
committees and in staff conferences as 
part of his training. 

B. He will attend local medical society 
meetings. 

C. He will be knowledgeable in all fac- 
ets of office management. 

IV. To Train Other Specialists in the 
Principle of Family Medicine (and how 
to professionally relate to the family phy- 
sician for better patient care) 

In order to complete these objectives, 
the resident will receive training in family 
medicine in the Model Family Practice 
Unit; in-hospital rotation through all ma- 
jor specialties, their clinics, and confer- 


August, 1974 — VOL. 126, No. 8 


275 


FAMILY PHYSICIAN— GEHRINGER 


ences; family medicine conferences per- 
taining to areas of special interest to a 
family physician; training outside of the 
hospital with preceptors in family medi- 
cine and various sub-specialties; rotation 
through clinics of various community 
health programs, ie, Public Health, Mental 
Health, School for the Blind, Mentally Re- 
tarded, Juvenile Court, Adolescent Clinic, 
Crippled Children Clinic, Psychological 
Testing, and electives in areas of particu- 
lar needs and/or areas where he would 
like to gain more expertise. 

Model Family Practice Unit 

The resident will learn the practice of 
family medicine in a Model Family Prac- 
tice Unit which is the most important and 
unique part of the Family Medicine Resi- 
dency Training Program. At the Earl K. 
Long Memorial Hospital, it provides a set- 
ting that is just like the office of a group 
practice of family physicians. In this unit, 
family medicine residents function as a 
large group practice of family doctors 
throughout the three years of residency 
training.' 

The physical plant and the personnel 
have been selected to provide and maintain 
this atmosphere. The present building is 
of modern steel construction and is located 
next to the Earl K. Long Memorial Hos- 
pital. The grounds immediately adjacent 
to the building are well landscaped, and a 
large sign with the words ‘‘The Family 
Doctor Clinic” and the American Academy 
of Family Physicians’ seal provides an ex- 
cellent view. 

Personnel consist of two graduate 
nurses, one nurse’s aide, one clerk typist, 
one stenographer, a social worker and a 
business administrator. Future plans in- 
clude increasing personnel workers as ad- 
ditional residents and staff are acquired. 
There will be a need for a laboratory and 
x-ray technician in the future. 

Medical staff consists of full-time and 
part-time board certified family physicians 
who provide continuous coverage for the 
unit. Two psychiatrists spend one half- 


day per week in the unit. One is a pedi- 
atric psychiatrist, and the other is board 
certified in transactional analysis. They 
provide consultation and act as leaders in 
conferences on various aspects of behavior. 
The residents in the program are provided 
continuing psychiatric consultations and 
are exposed to the different approaches 
available in handling behavioral problems. 
Further input into behavioral problems 
within the family is obtained from social 
workers. 

Consultations also include other full- 
time and part-time staff of the Earl K. 
Long Hospital in the various specialty and 
sub-specialty groups, who are faculty mem- 
bers of the Louisiana State University 
School of Medicine. 

Laboratory 

Laboratory facilities in the Model Fam- 
ily Practice Unit are similar to those 
found in a family medicine private clinic. 
Facilities to do blood sugars, CBCs, com- 
plete urinalysis, and hematocrits are found 
within the unit. The Pathology Depart- 
ment at the Earl K. Long Hospital pro- 
vides additional needed services. 

X-ray 

X-ray services are available in the hos- 
pital. All x-rays obtained are read by the 
residents and their preceptor-staff in the 
Model Family Practice Unit in collabora- 
tion with the radiologist. This allows resi- 
dents the opportunity to learn to read their 
own films. When the projected Model 
Family Practice Unit is completed, it will 
contain x-ray facilities for simple office 
procedures. 

Other Equipment 

The Model Family Practice Unit has its 
own electrocardiogram machine. ECGs 
are done by the residents and/or nurses, 
and are read by the resident with precep- 
tor supervision prior to review by the 
cardiologist. 

Fiber optic proctoscopy equipment, bi- 
opsy supplies, and a Hyfrecator are avail- 
able to the residents. For treatment of 


276 


J. Louisiana State M. Soc. 


FAMILY PHYSICIAN— GEHRINGER 


fractures, all equipment for casting is on 
hand. 

The Model Family Practice Unit is to 
the family medicine resident what the op- 
erating suite is to the surgery resident. It 
is in this unit that he is trained in the arts 
and skills of his specialty (primary and 
continuing comprehensive care) . Much of 
the knowledge acquired by family medi- 
cine residents is gained in rotating through 
various other specialty and sub-specialty 
services. However, it is in the Model Fam- 
ily Practice Unit that he puts it all to- 
gether, as family medicine, under the 
supervision of board certified family phy- 
sicians. 

While in the Model Family Practice 
Unit, residents are required to work at a 
deliberate and slow pace. The emphasis is 
on complete and total evaluation as it re- 
lates to the family group. 

Considerable time is allowed for an 
initial visit. As the resident matures and 
as his families increase, the time required 
to evaluate patients decreases. The third 
year resident is expected to function with 
the same speed and efficiency as a private 
practicing family physician. 

Residents spend an ever increasing 
amount of time in the Model Family Prac- 
tice Unit from the first through third 
years of training. First year residents are 
assigned 25 families (100 patients) initial- 
ly. The second year residents will increase 
this number to approximately 70 families 
(180 patients). By the time a resident 
reaches his third year, his families may 
number 100 (400 patients) or more. 

These families are referred from the 
Earl K. Long Hospital Clinics, from pri- 
vate physicians, and from specialty ser- 
vices in the Earl K. Long Hospital who 
feel a particular patient or family needs a 
regular physician. Some come from social 
agencies and walk-in applications from 
families who have heard of the program 
from other patients. There is a long wait- 
ing list of families who need a regular 
family physician. 


Model Family Practice Unit 
Procedures 

The resident sees his patients by ap- 
pointment in the Model Family Practice 
Unit. If patients come in without an ap- 
pointment, they are seen by the residents 
in the office at the time and then reap- 
pointed to see their regular family medi- 
cine resident. 

The residents and staff have an on-call 
schedule; and when the Model Family 
Practice Unit is closed, the patient is in- 
structed to call or come to the Emergency 
Room, and the resident on-call for the 
family medicine residency group practice 
is notified and cares for the patient’s needs 
as it is done in a private group practice. 

Residents admit patients from the fam- 
ilies assigned to them to the Earl K. Long 
Hospital when hospitalization is needed. 
They make daily rounds on their family 
medicine patients with family medicine 
staff supervision. 

Consultation is encouraged because of 
its importance as a learning experience 
and is requested whenever it is indicated. 
If the problem becomes surgical, the pa- 
tient is transferred to surgery for primary 
responsibility. The family medicine resi- 
dent continues to follow the patient 
through surgery and as a member of the 
surgical team participates in the manage- 
ment to the extent commensurate with his 
level of training. 

Residents follow obstetrical patients in 
the Model Family Practice Unit as family 
physicians do in private practices. At de- 
livery, the woman’s family medicine resi- 
dent is notified; and he serves as her phy- 
sician during and after delivery in the hos- 
pital under the supervision of OB-Gyn and 
family medicine staff. 

Residents make house calls when indi- 
cated. Indications are similar to those in 
a standard family practice; and include 
non-hospital emergencies, care of the aged, 
chronic illness and post-hospitalization 
follow-up. On initial house calls, the fam- 
ily medicine residents are accompanied by 


August, 1974 — Vol. 126, No. 8 


277 


FAMILY PHYSICIAN— GEHRINGER 


staff and thereafter each call is reviewed 
for need of staff accompaniment. 

Problem oriented medical records are 
kept on all patients in the Model Family 
Practice Unit. 

Residents are exposed to patient ap- 
pointment scheduling and routine business 
procedure. A set of books is kept, and rel- 
ative value schedule for charges is used. 
All diagnoses, procedures, laboratory tests, 
x-rays, ECGs, and financial charges are 
coded by the business office. The informa- 
tion is fed into a computer. Computer feed- 
back provides valuable information as to 
types of problems, procedure, laboratory 
tests, etc. on each resident; and in turn 
this helps to direct the residents’ and 
staff’s attention to areas of need. 

It should be noted that the family medi- 
cine resident serves in all clinics and the 
Emergency Room throughout his three 
years of training. He works side by side 
with the residents on the service to which 
he is assigned. He is excused from wards 
or clinics on these services when he is as- 
signed to the Model Family Practice Unit. 

The service provided in the Model Fam- 
ily Practice Unit is the most comprehen- 
sive medical attention these patients have 
ever received in a university setting. 

In-hospital Training 

During the first year, the family medi- 
cine resident gets a good clinical founda- 
tion by rotation through all traditional 
specialties of internal medicine, surgery, 
pediatrics and OB-Gyn. Emphasis during 
the entire first year is on primary care. 

He also spends two months in the Emer- 
gency Room which handles all emergen- 
cies, whether they are surgical, medical, or 
emotional under the supervision of full- 
time Emergency Room staff. 

The second year is designed to enhance 
the resident’s skills in primary care in all 
major disciplines plus developing new 
skills in the major sub-specialty areas seen 
most frequently in family medicine. This 
is accomplished by in-hospital rotations 
and tenures in private specialty and sub- 


specialty groups. He increases his time 
spent in the Model Family Practice Unit 
and increases his family load to a mini- 
mum of 70 families (approximately 280 
patients) . 

The third year resident should be ma- 
ture enough medically to recognize some 
of his basic needs whether it be areas of 
weakness or areas where he would like to 
gain more expertise. These needs are 
filled on an individual basis by in-hospital 
rotation and tenure in private specialty 
and sub-specialty practices. Even though 
the third year is somewhat formalized, 
there is a great deal of flexibility in the 
structure. 

The third year resident continues to in- 
crease his time spent in the Model Family 
Practice Unit and increases his family load 
to a minimum of 100 families (approxi- 
mately 400 patients). 

In the second and third year, the resi- 
dents rotate through ENT, dermatology, 
orthopedics and GU with emphasis on pri- 
mary and ambulatory care. They are also 
taught the recognition and principles of 
management of more complex problems. 

Family medicine residents work at peer 
level with other specialty residents on all 
services. This does not mean that they are 
as technically skilled in surgery as their 
surgical resident counterparts, but it does 
mean that they are regarded as equal in 
general medical knowledge and patient 
management. 

Preceptorship in Family Medicine 

The senior resident spends one month 
in a family practice of the type in which 
he feels he is primarily interested. The 
other month is spent in a family practice, 
as nearly as possible, in an opposite set- 
ting; ie, metropolitan vs. urban vs. rural 
areas and large group vs. small group. 
Preceptors are chosen by the staff, and the 
resident works under their supervision. A 
formal evaluation is obtained from the 
preceptor at the completion of the period. 
This helps the resident in deciding on the 
type and location of practice he will enter. 


278 


J. Louisiana State M. Soc. 


FAMILY PHYSICIAN— GEHRINGER 


Electives 

There are two types. One is designed to 
help the resident gain more knowledge and 
skills in areas where staff has found him 
to be deficient. The other is designed to 
aid the resident in gaining more expertise 
in areas where he has special interest. 

Conferences 

Residents attend all family medicine 
conferences. Once a month, the conference 
is televised via the Louisiana Hospital 
Television Network. Conferences include 
topics such as economics, office manage- 
ment, office ENT, GU, dermatology, 
medicolegal problems. Medicare, Medicaid, 
physician’s liability insurance, athletic in- 
juries, etc. 

Evaluation 

Throughout their training, residents are 
evaluated on each service through which 
they rotate by the staff of that service. 
Each patient visit in the Model Family 
Practice Unit is reviewed, and the resident 
has direct feedback from his preceptor 
when they review the chart together. 


A computer evaluation form is com- 
pleted by the preceptor on each patient 
visit in the Model Family Practice Unit, 
and this information is stored in the com- 
puter to aid in program planning. 

Program evaluation is handled by staff 
and resident feedback and consultation 
from visiting department heads, American 
Academy of Family Physicians, Louisiana 
Academy of Family Physicians, and the 
AMA Residency Review Committee for 
Family Medicine. 

Summary 

When our residents complete their three 
years of training, as outlined, they will be 
well prepared and ready to begin their 
tenure at private practice. They will be 
truly the patients’ and families’ health ad- 
visors in the vast world of medicine. They 
will be able to serve their community as 
leaders in health care and social needs. 
The type of training these young physi- 
cians are receiving will enable them to 
fulfill the needs of the patient, the family, 
the medical profession, and the community 
as a whole. 



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August, 1974 — Vol. 126, No. 8 


279 



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Doctor-Patient Rapport 

• A project was designed to measure rapport established between 
doctor and patient during an office visit. 

RANDALL JOHNSON SMITH* 
New Orleans 


'^HIS two month project was designed 
as a crude attempt to measure rapport 
established between doctor and patient 
during an office visit. With the exception 
of preceptors observed in the Emergency 
Room, the doctors were all residents in 
the Family Practice Training Program at 
the Earl K. Long Memorial Hospital in 
Baton Rouge. The physicians and patients 
were unaware of the criteria for the ‘‘per- 
fect” doctor-patient relationship and were 
not aware they were being observed for 
their relationship. 

The measurement of rapport, the rela- 
tionship of harmony between two persons, 
is difficult to make into an objective list 
of questions that requires only a “yes-no” 
answer on the observer’s part without sub- 
jective bias entering the observation. Since 
the criteria were identical for all doctors 
at all levels, a comparsion may be drawn 
between the residents at each year of pro- 
gression through the Family Practice Res- 
idency Program. The questions were de- 
vised after several conferences with the 
faculty of the Family Practice Program to 
determine desirable actions on the physi- 
cian’s part. They were indirectly devised 
from The Fine Art of Understanding Pa- 
tients by R. C. Bates, MD. 

Criteria used in the study were: 

1. Touch Patient — Does the doctor 
touch the patient at any time other than 
in greeting or during the physical exami- 
nation? This is considered the classic “lay- 
ing on of hands.” 

2. Interest in Patient's Life — Is there 
any direct question by the physician con- 
cerning the patient’s life, home, family, or 
social situation? 


* Fourth year medical student, LSU School of 
Medicine, New Orleans. 


3. Secondary Problems — Does the doc- 
tor ask the patient about any problems 
other than the primary one? 

4. Patient Conversation — Does the pa- 
tient initiate any original conversation not 
following a direct question by the doctor? 
This also determines whether the doctor 
allows time for the patient to talk. Does 
the doctor listen? 

5. Explain Diagnosis — Does the doctor 
explain his diagnosis in terms a layman 
could understand? 

6. Therapeutic Plan — Does the doctor 
discuss his treatment plan with the pa- 
tient, explaining what is expected of the 
patient? 

7. No Degradation — Is there any state- 
ment by the physician after the interview 
that degrades the patient or the patient’s 
situation ? 

A total of 86 observations was made in 
the Model Family Practice Unit while 206 
observations were made in the Emergency 
Room. 

A few trends may be noted from the 
data in Table 1. Doctors appear to demon- 
strate a greater degree of rapport with 
their patients in the Model Family Prac- 
tice Unit than when these same doctors 
see patients in the Emergency Room. Pre- 
ceptors consulting in the Emergency Room 
score about the same as 2nd year family 
practice residents. 

There are several areas in the family 
practice interview that vary between the 
years of residency. A significant decline 
occurs between second and third year doc- 
tors in touching patients. While second 
year doctors almost always “lay on the 
hands,” third year residents only touch pa- 
tients 61 percent of the time. Family prac- 
tice residents show interest in their pa- 


August, 1974 — VOL. 126, No. 8 


281 


DOCTOR-PATIENT RAPPORT— SMITH 


tients’ lives approximately half the time, 
and this doesn’t change through their 
training. Residents do become more com- 
plete in their office interview from the 
medical standpoint, asking the patients for 


their secondary problems more often. A 
steadily decreasing number of patients are 
spoken of in a degrading way as the resi- 
dents continued through the program. 

The Emergency Room interview can 



FAMILY 
1 1 

PRACTICE RESIDENT (Year) 
1 2 1 3 1 

Preceptor 

FAMILY PRACTICE UNIT 

Total Number of Observations 

37 

36 

13 

0 

Touch Patient 

83% 

94% 

61% 

- 

Interest in Patient *s Life 

52% 

50% 

61% 

- 

Ask about 2° Problems 

57% 

66% 

83% 

- 

Pt. initiates conversation 

60% 

87% 

75% 

- 

Explain 

90% 

87% 

80% 

- 

Explain Therapeutic Plan 

84% 

87% 

90% 

- 

Pt. not Degraded 

Overall Average 

89% 

|74%] 

94% 

[ng 

100% 

R8%1 

- 

Table 1. 
EMERGENCY ROOM 





Total Number of Observations 

59% 

43% 

0 

104 

Touch Patient 

89% 

90% 

- 

90% 

Interest in Patient 's Life 

17% 

18% 

- 

20% 

Ask about 2° Problems 

29% 

32% 

- 

44% 

Pt. initiates conversation 

49% 

56% 

- 

62% 

Explain 

84% 

95% 

- 

98% 

Explain Therapeutic Plan 

84% 

95% 

- 

95% 

Pt . not Degraded 

85% 

88% 

- 

87% 

Overall Average I 

60% ] 

( 68% 

1 


Table 2. 






282 


J. Louisiana State M. Soc. 


DOCTOR-PATIENT RAPPORT— SMITH 


hardly be judged by the same standards as 
the family practice interview. The Emer- 
gency Room at the Earl K. Long Memorial 
Hospital operates primarily as a walk-in 
clinic. Patients are seen in volume, and 
residents seldom have any follow-up re- 
sponsibilities for these patients. In this 
atmosphere, the resident can conduct the 
office interview in any manner he desires. 
In every category except explaining the 
diagnosis and therapeutic plan, the Emer- 
gency Room residents score lower (Table 
2). No third year residents are observed. 
Every category shows a steady increase as 
one progresses from intern to preceptor 
level. The habit of touching the patient 
apparently develops during the first year 
of residency. Interest in the patient’s life 
is shown very seldom (18 percent) in the 
Emergency Room situation. Two thirds of 
the time, physicians did not ask about sec- 
ondary problems. Almost as many pa- 
tients initiate conversation in the Emer- 
gency Room as in the Family Practice 
Unit. This percentage increases as the 
resident moves through the program. The 
diagnosis and therapeutic plan are well ex- 
plained. Only 10 percent of the patients 
are degraded in the Family Practice Unit. 

Conclusions possible from this data 
would show that the physician will vary 
in his performance according to the de- 
mands of the situation. Residents are ex- 
pected to have good rapport with their own 
families in the Model Family Practice 
Unit, while they have little pressure in the 
Emergency Room other than to see as 
many patients as possible. The interesting 
aspect is that the overall scores for rap- 
port vary only by 10 percent between the 
two situations. This speaks highly for the 
personality of the family practice resident. 
From the standpoint of progression 
through the training programs, internship 
to graduate, there is still about a ten per- 
cent point difference. The categories show 
that residents’ medical thoroughness de- 
velops in the training program while their 
basic personalities can be changed little. 


Acknowledgement 

I thank George L. Lawrence, a fellow 
student, for assisting in collecting and 
compiling the data. 


<s=3C=» 


WANTED 

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GP needed to work part-time or full-time 
in the Neighborhood Health Program in 
New Orleans. Pay compatible with experi- 
ence. Opportunity to establish on limited 
basis clinics in specialty areas. Call or 
write Dr. Sandra Robinson, Model Cities 
Health Centers, 136 South Roman, New 
Orleans, Louisiana 70112 . . . An Equal 
Opportunity Employer. 


T»f 


O 


ROYAL CROWN-COLA 

TSt 


August, 1974 — Vol. 126, No. 8 


283 




A Health Education Program for the Public 

• The program was designed to fadlitate and strengthen health 
care through education. It constituted a unique effort by five 
organizations to unite their resources for a better quality of life 
in Louisiana. 


'^HREE units of Louisiana State Uni- 
versity are working with the Louisiana 
Department of Hospitals and the State 
Board of Health to test pilot consumer 
health education programs in rural areas 
near Baton Rouge. 

Health department, hospital and univer- 
sity officials have become concerned over 
a growing crisis in health care. People are 
demanding more from the system; and at 
the same time, they have a general defi- 
ciency of knowledge of good health care 
practices. With added programs and mush- 
rooming technology, the health care sys- 
tem is becoming more and more complex. 
Difficulties in dealing with this complex- 
ity are particularly acute among low- 
income people, who are not effectively 
reached through the channels of infonna- 
tion dissemination most often used by 
educational institutions. 

The general lack of basic health knowl- 
edge was indicated by a survey of 228 
homemakers in 8 Capitol area parishes 
in 1972. Only 29 percent of the homemak- 
ers knew the normal body temperature, 
and only 15 percent could compute how 
much fever a person with a given tem- 
perature had. 

Many homemakers believed in tying ob- 
jects around various parts of the body to 
treat certain ailments. They treated teeth- 
ing problems by tying a silver dime, swamp 
root beads, whole nutmeg, the stem of a 
pumpkin or the tongue of an old shoe 
around the infant’s neck. Placing straw 

* Area Agent, Orleans Parish Manager, Agri- 
culture Business Department, Chamber of Com- 
merce of the New Orleans Area. 

This project was supported by a grant from 
the Louisiana Regional Medical Program. 


BILLY J. GREENE, MS* 
New Orleans 

on a baby’s head was considered good for 
treating worms and shortness of breath. 

For health information, 63 percent de- 
pended on relatives or friends. When they 
needed advice about a health care problem, 
55 percent said they had no source they 
could depend on. For treatment of a health 
problem, however, 94 percent used a doc- 
tor, nurse or a health facility. 

Other studies indicate that one out of 
three children is not properly immunized 
against polio, and the number of children 
vaccinated against measles had dropped 
markedly in the past three years. 

About half of the families in the Louisi- 
ana survey consisted of 5 to 12 members. 
Most mothers did not work, and 73 percent 
had less than a high school education. 
Fifty-seven percent of the families had an 
annual income of less than $3,000. 

LSU’s Medical School, Division of Fam- 
ily Medicine, Division of Continuing Edu- 
cation and Cooperative Extension Service 
assumed responsibility for developing an 
educational program, utilizing also the 
technical and educational capabilities of 
the State Health Department and the pa- 
tient contacts of the Department of Hos- 
pitals. 

The medical school served as the knowl- 
edge base, while the Continuing Education 
Division contributed its competence in or- 
ganizing and delivering specialized train- 
ing programs, and the Extension Service 
added its capability for reaching audiences 
in their homes and communities with in- 
formal education. 

Experience of the Extension Service had 
indicated that low-income persons must be 
reached in their own environment by peo- 
ple they respect and with whom they can 


284 


J. Louisiana State M. Soc. 


HEALTH EDUCATION PRO GKAM— GREENE 


communicate. They rarely move out of 
their environment and rarely respond to 
people who are culturally different except 
perhaps under desperate circumstances. 

Two audiences were selected for the 
pilot educational program — low-income 
families and the general public. 

Some 700 indigent families have been 
enrolled in the program. These include 
clientele of the LSU Medical School’s Fam- 
ily Practice Unit, families enrolled in the 
Cooperative Extension Nutrition Educa- 
tion Program and some who had no pre- 
vious organizational contact. 

Four health aides were employed from 
communities where the program was to 
operate, and nutrition aides already em- 
ployed by the Cooperative Extension Ser- 
vice were given the added responsibility 
of delivering health care information. 

The Health Educational Program Staff 
trains the aides with assistance from the 
medical school. As teaching units are pre- 
pared on a single health practice, they are 
reviewed by the staff of the medical school. 
Aides are then trained for this one teach- 
ing unit. 

The aides present the unit to the fam- 
ilies they have enrolled, usually about 75 
families per aide. They try to meet fam- 
ilies in groups of 5 to 10 where possible, 
but most training is given individually in 
the homes. 

Units that have been presented include: 
How to Take Temperature; When Should 
You Call the Doctor After Hours; Your 
Heart; Sickle Cell Anemia; What You 
Should Know About Diabetes; Start Early 
with Immunization; and Parasites That 
Need Attention. 

Aides report that all of the units have 
been received well. With the unit on dia- 
betes, for example, clients often responded, 
“So that’s why the doctor wants me to take 
insulin and not eat certain foods!” Most 
families like the special interest the aides 
take in them . . . their willingness to make 
a home visit to talk about health concerns. 

The program for the general public has 


included preparation of a method demon- 
stration, “Keep Your Teeth for a Life- 
time.” Professional cooperative extension 
agents have presented this demonstration 
to some 6,000 young people. 

In Livingston Parish, a Consumer Health 
Education Committee was formed to con- 
duct a hypertension screening program. 
They coordinated an effort involving the 
school system, the sheriff’s office, civic 
groups, all news media in the area and the 
medical profession. Some 150 volunteers 
contributed their time on a Sunday after- 
noon; and 1,500 citizens came in to have 
their blood pressure measured. In addi- 
tion to pointing out people with problems 
or potential problems, the effort made peo- 
ple more aware of the importance of prop- 
er blood pressure and of the problems that 
could result from improper pressure. 

The program was designed to facilitate 
and strengthen health care through educa- 
tion. It constituted a unique effort by five 
organizations to unite their resources for 
a better quality of life in Louisiana. 




WANTED 

GENERAL PRACTITIONER. INTERNIST or GEN- 
ERAL SURGEON to serve as Outpatient Physician, 
including admissions. New VA Hospital with 
active teaching and residency program. Salary 
based on qualifications according to VA salary 
scale. 40 hour basic work week. Liberal fringe 
benefits. Non-discrimination in employment. 


Write Chief of Staff, VA Center, Jackson, Miss. 
39216. 


August, 1974 — Vol. 126, No. 8 


285 


Electrocardiogram 
of the Month 


Editors 

JOE W. WELLS. MD 
NORTON W. VOORHIES, MD 
ADOLPH A. FLORES. JR., MD 
LAWRENCE P. O’MEALLIE. MD 
New Orleans 


D. S. PARAGUYA, MD 
Lake Charles 


A 52-year-old diabetic woman was seen complaining of chest pain. Her EKG is 
shown below: 












- - 






— Ji' 





— 1 


i 





--I 






1 

, 

t-g. li = 


-J 

* r 












A,::. . 

=if- 

: r- « 




i 







--f- 


4- 



:=| 




i- 











AVR AVL 



What is your diagnosis? 
Elucidation is on page 288. 


286 


J. Louisiana State M. Soc. 


i^aaioio ^i^ ! a^e 


Mistaken Diagnosis Possible 

D. S. PARAGUYA, MD 
F. MAREK, MD 
Lake Charles 


A 54-year-old woman was admitted 
complaining of a “cold” of two 
weeks’ duration, chest pain and exer- 
tional dyspnea. 

P.E.: B/P-190/110; P/R-85/min.; 

Temp.-98° F 


The patient was well oriented, am- 
bulatory and in no acute distress. Both 
lungs were essentially clear. Heart rate 
was regular at 85/min. Heart murmurs 
were heard. 

Below is her initial chest x-ray. 



What is your diagnosis? 

See page 290 for elucidation. 


August, 1974 — ^Vol. 126, No. 8 


287 


ELECTROCARDIOGRAM OF THE MONTH 


Electro- 
cardiogram 
of the Month 


ELUCIDATION 


This EKG tracing was improperly taken, 
in that the electrode wires were crossed. 
Among the clues to this are the unusual 
QRS axis, the negative P waves in I and 
positive P and R waves in AVR. Also, the 
tracing was markedly different than a 


recent previous one. 

This tracing is shown to emphasize two 
things: 

In interpreting EKGs, comparison with 
previous tracings ought to be made; and 
artifacts, due to improper electrode con- 
nection or placement, should be kept in 
mind. 


HieeRDia 

nanonaL 


288 


J. Louisiana State M. Soc. 



^Flfjecllcai GranJ- ^oundi 


Athletic Injuries 


Dr. Gerald R. Gehringer : Because 

many family physicians are called upon 
to serve as team physicians in their com- 
munities, it was felt that a discussion of 
athletic injuries would be beneficial to 
those presently involved in school ath- 
letic programs and to potential school 
physicians. 

Time does not allow for an in-depth 
discussion of all athletic injuries so we 
will limit this conference to medical de- 
cisions that need to be made on-the-field 
at the time of injury. 

I would like to ask Dr. Broussard to 
make a few comments about pre-season 
conditioning and fluid and electrolyte 
problems in football players. 

Dr. Marty Broussard The Louisi- 
ana High School Association requires 
that high school football players work 
out in shorts, helmets and pads for the 
first five days of practice. At LSU, our 
boys work out in shorts for only three 
days; however, it should be understood 
that the conditioning program for LSU 
football players begins on July 1. Three 
days before football practice begins, 
each athlete is subjected to a pretty 
strenuous physical fitness examination 
to determine whether he has been ad- 
hering to the conditioning program. High 
school coaches could begin a similar pro- 


Presented by the Louisiana State University 
Family Medicine Residency Training Program at 
the Earl K. Long Memorial Hospital, Baton 
Rouge. 

Director, Family Medicine Residency Train- 
ing Program, Earl K. Long Memorial Hospital; 
Assistant professor of medicine, LSU School of 
Medicine, New Orleans. 

('’^LSU football team trainer; Professor of 
physical education, LSU. 


Edited by SYDNEY JACOBS, MD 
New Orleans 

gram to take care of themselves during 
practice season. 

As far as an electrolyte drink is 
concerned, we use an isotonic quick-en- 
ergy, thirst-quenching drink of which 
there are only two such on the market: 
‘‘Gatoraide” and ‘Quick-Kick.” We find 
that “Quick-Kick” is a strictly isotonic 
solution with an osmotic pressure equal 
to that of blood plasma. We do not 
restrict our players to just electrolyte 
drinks. About every hour and a half. 
Coach McClendon allows the boys a 
seven to ten minute break during which 
time they are allowed isotonic fluids ac- 
cording to their size and requirements. 

I would like to read some material 
referring to heat problems and the en- 
vironmental conduct of athletics, par- 
ticularly football. This is a little long 
but every line is important: 

General Warnings — Most adverse re- 
actions to environmental heat and hu- 
midity occur during the first few days 
of training. It is necessary to become 
thoroughly acclimated to heat to suc- 
cessfully compete in a hot or humid en- 
vironment. Athletes, those particularly 
susceptible to heat injuries, are: those 
unaccustomed to working in the heat; 
overweight individuals (particularly 
large linemen) ; those who constantly 
compete at top capacity; and those who 
are ill in any way or who have febrile 
immunization reactions. 

Prevention of Heat Injuries — Provide 
complete medical history and physical 
examination. Include a history of pre- 
vious heat illnesses, fainting in heat, in- 
juries from sweating and peripheral vas- 
cular defects. Evaluate the type and 
duration of training activities for pre- 
vious months. 


August, 1974— Vol. 126, No. 8 


289 


MEDICAL GRAND ROUNDS— Earl K. Long Memorial Hospital 


General Training Activities — Acclimate 
athletes to heat gradually by requiring 
them to work in the heat. They can’t 
work in the shade and participate in 
the heat. Recommend type and variety 
of warm weather workouts for pre-sea- 
son training. Provide a graduated train- 
ing program for the first seven or ten 
days on abnormally hot days or humid 
days. 

Body Weight Loss — Water loss and salt 
loss during activity in heat should be 
replaced as they are lost. Supply elec- 
trolyte replacement fluid, preferably one 
with potassium, as well as sodium chlo- 
ride. Potassium actually is a safeguard, 
for as we sweat we lose potassium. So- 
dium chloride goes into the body cells 
and this creates an electrolyte imbalance. 
Allow additional water. Provide salt 
on the training table and encourage the 
players to add salt to food. It is not 
necessary that salt tablets be taken. 
Treat athletes who lose an excess of 
weight each day. Treat well conditioned 
athletes who continually lose weight for 
several days. 

Clothing and Uniforms — Provide light- 
weight clothing that is loosely fitted at 
the neck, waist and sleeves. Use shorts 
and tee shirts at the beginning of prac- 
tice. Avoid excessive padding and tap- 
ing. Avoid use of all stockings, rubber- 
ized clothing or sweatshirts, long sleeves, 
double sleeves and other excessive cloth- 
ing. Provide clean clothing daily, all 
items. Provide a rest period to dissipate 
accumulated body heat. Rest in a cool 
shaded area with some air movement. 
Loosen or remove jerseys or other gar- 
ments while resting. Avoid hot brick 
walls or hot benches. 

We feel that salt tablets usually do 
more harm than good. Some athletes 
take too many and have gastrointestinal 
disturbances, usually cramps and fa- 
tigue. There is no excuse for any coach 
ever going on the practice field with- 
out knowing the temperature and hu- 
midity. He can obtain this information 


from local radio stations or the weather 
bureau. Today, the temperature is 68 
degrees ; however, the humidity is 95 
percent. You would think there would 
be no danger by participation in football 
gear; however, it is a typical day to be 
watchful for heat illness. Unless a player 
is ill, heat injuries indicate poor super- 
vision. 

The most common trouble signs of 
heat problems we see are : headaches, 
incoherence, cramps, cyanosis, nausea, 
vomiting, visual disturbances, seizures, 
flushing, slowness in mentality, fatigue, 
rigidity, fainting, weakness, unsteadi- 
ness, diarrhea, chills, and a rapid pulse 
rate. 

Dr. Gehringer : Dr. Broussard do you 
limit the amount of fluid an athlete takes 
in at any one time? 

Dr. Broussard: Yes, we do. Large 

boys or heavy players drink eight to 
ten ounces 40 minutes before practice 
begins. At the ten minute break every- 
body gets ten ounces of isotonic solu- 
tion, and after practice they can actually 
drink as much as they want. One ad- 
vantage to isotonic products is that play- 
ers can drink as much as 30 to 40 ounces 
without feeling “bloated” ; and there- 
fore, it does not interfere with the boys’ 
evening meal. 

Dr. Gehringer: Let’s move on now to 
actual on-the-field decisions. Dr. Baquet, 
we would like you to discuss what should 
be done when a player receives a severe 
blow to the head and is knocked out, or 
as football players say “gets his bell 
rung.” How do you go about deciding 
whether or not you are going to let this 
player go back into the game? 

Dr. George Baquet I think when a 
physician is called on the sideline to ex- 
amine a player lying motionless on the 
field, he has to be able to evaluate sev- 
eral factors. The first is, the degree of 
impact. Naturally a 200-pound-fullback 

(‘=)Redemptorist high school athletic physician; 
Clinical assistant instructor of medicine, LSU 
School of Medicine, New Orleans. 


290 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Earl K. Long Memorial Hospital 


colliding with a 160-pound-linebacker 
delivers quite a bit of force, especially 
if the contact is on the head, as opposed 
to that of a minor bounce off the ground 
with protective equipment on. Secondly, 
we must evaluate the degree of black- 
out: Is it syncope or unconsciousness or 
amnesia ? Remember that headaches are 
also significant. It takes 20 or 30 sec- 
onds for you to arrive on the football 
field ; so if the player is awake, think- 
ing, and recognizes you, then he prob- 
ably does not have a concussion. If he 
isn’t capable of all these functions, you 
have to treat him as if he had sustained 
a concussion. I hospitalize such players 
and watch them carefully with neuro- 
logical monitoring. After a period of ten 
days, if everything is uneventful, the 
player is allowed to return to contact 
sports. If during the time of observation 
he develops any kind of difficulty or 
has abnormal neurologic findings, then 
I obtain a neurological consultation. I 
don’t think we have had more than a 
handful of epidural or subdural hema- 
tomas related to organized contact sports 
in Baton Rouge in the last ten years; 
but such injuries are catastrophic. 

Severe head injuries are uncommon. 
I would like to mention a problem that 
occurs more frequently: The determina- 
tion of when a player should be barred 
from further contact sports because of 
head injuries. If a player has had three 
documented cerebral concussions or has 
had any intracranial surgery, contact 
sports are definitely contraindicated. 
Post-traumatic headaches can be dis- 
abling and can prevent further parti- 
cipation in sports. 

Dr. Alvin Stander:^'^) When a player 
has had a mild concussion and you do 
not want him back in the game, take his 
helmet away. If you have his helmet, 
he can’t get back in. 

Dr. Gehringer: Good comment. Dr. 

(<5)LSU football team physician; Clinical assis- 
tant professor of orthopedics, LSU School of 
Medicine, New Orleans. 


Stander. Now Dr. Baquet, we would like 
to hear some of your comments on in- 
juries to the cervical spine. Coaches 
teach “spearing techniques,” and the 
head is used as a battering ram. If the 
player is a bit off center he may incur 
a neck injury. Also, the face mask is a 
beautiful handle, and players are using 
it to wring other player’s necks. 

Dr. Baquet: Next to abdominal and 
head injuries, probably neck injuries are 
the most severe. Probably everyone has 
heard of the football player who is now 
quadriplegic because of a neck injury. 
When a physician is faced with a foot- 
ball player on the field with a neck in- 
jury, he has a problem. 

Is he going to immobilize every neck 
injury with sandbags? — Put the player 
on a stretcher? — Bring him to the hos- 
pital and get x-rays ? Or is he going to 
rely on a physical examination for signs 
of neurologic deficit before he does he- 
roic things? 

There is no real solution to these 
questions. If the physician does a good 
examination and is alert for any indica- 
tion of deep cervical injury, then prob- 
ably he will detect most of these injuries. 
Some deep injuries will present little or 
no symptoms; so the team doctor will 
probably miss a few. However, when 
there is any doubt, emergency measures 
must be taken. Adequate examination 
consists of analysis of the mechanism of 
injury, inspection of the neck, talking 
with the player, and feeling his neck. 
Dr. Gehringer mentioned a face mask 
being a good handle. This is one of the 
mechanisms you see quite often. It pro- 
duces hyperflexion, bending of the head 
forward, which causes injury. This is 
what we ask the player. Was your head 
bent forward ? — Backward ? 

In a case of hyperextension, the back 
of the helmet actually acts as a guil- 
lotine capable of inflicting bony or mus- 
cular injury. Another mechanism of in- 
jury is lateral flexion in combination 
with or without rotary forces. 


August, 1974 — Vol. 126, No. 8 


291 


MEDICAL GRAND ROUNDS— Earl K. Long Memorial Hospital 


On the field, one may determine the 
mechanism of injury by asking the ath- 
lete where it hurts, whether his arms 
feel strange, is there any paresthesia or 
numbness of the hands, and whether he 
can move his legs. If these are in order 
and he doesn’t show any obvious signs 
of immediate neurologic deficit, then ex- 
amine his neck. By palpation of the 
large neck muscles, you can determine 
whether there is any hemorrhage in 
the muscle or if there is any swelling 
or tenderness. These things will indicate 
if the injury is superficial. 

If, however, you palpate deep to the 
larnyx or the glottis or posterolateral to 
the spines of C 3 to C 7 and you find 
marked tenderness, a hematoma or you 
produce pain, then you are eliciting signs 
of deep neck injury. 

This is a good time to mention the 
most common neck injury we see on the 
field : a “hot shot.” This results when 
the head is forcibly laterally flexed to 
either side causing pinching of a cer- 
vical plexus of nerves as it exits behind 
the border of the sternocleidomastoid 
muscle. The player usually complains 
of immediate burning, searing, pain over 
the shoulder. When you examine this 
boy, you ask him where it hurts. When 
lateral flexion of his head away from 
the affected side produces symptoms or 
makes them worse, you can assume that 
he has a pinched nerve. Have this boy 
sit out a few minutes, and if the pain 
subsides in about two or three minutes 
leaving him with only a paresthesia, he 
may return to the game with no worry 
of a serious neck injury. However, if 
flexion of the head toward the affected 
side causes pain, a numbness in his arm 
or radicular pain down toward his thumb 
or hand, he has a deep cervical injury — 
which may mean that the player has 
sustained : a fractured cervical vertebra, 
an intervertebral foramen compression 
fracture or a rotary subluxation. All of 
these are emergencies, so you must move 
these players out before they suffer fur- 


ther damage. Concerning neck injuries, 
you’ve just got to do a decent physical 
and look for signs of deep cervical in- 
jury. If there is any doubt in your mind, 
treat the player by getting the sandbags 
out and rush him to the hospital for 
definitive care. 

Dr. Gehringer : Thank you. Dr. Baquet. 
Dr. Stander, would you like to comment 
on the neck injuries before we go on to 
the next question ? 

Dr. Stander: I think Dr. Baquet has 
covered it very well, and I compliment 
him on the presentation. When you do 
have pinched nerves, use the collar to 
limit the neck motion, flexion and ex- 
tension. They ought to be limited to 
prevent flexion because most injuries are 
in flexion. 

Dr. Gehringer: Dr. Broussard, when 
you get neck muscle injury like this, 
what type of physical therapy do you 
use ? 

Dr. Broussard: We prefer intermit- 
tent traction ; but we also use diathermy, 
ultrasound, steam baths, hydrocircular 
packs, whirlpools, and massage. 

Dr. Gehringer: How long does it take 
a muscle strain in the neck to improve ? 

Dr. Broussard : If we are lucky, 10 
or 15 days; sometimes it takes longer. 

Dr. Gehringer: Let’s move on to a 

discussion of shoulder injuries. Dr. Stan- 
der, when you see a player coming off 
the field holding his arm next to his side 
with an obvious shoulder injury, how do 
you handle him? 

Dr. Stander : The most common thing 
is the contusion of the shoulder, or a 
bruise. The shoulder is really one of 
the better protected parts of the body. 
Less often than contusion of the shoulder, 
we see acromioclavicular strain. The 
A/C joint is where the clavicle joins the 
acromion process, and it has some good 
ligaments. 

We check it by palpation of the joint 
with traction and movement of the 
shoulder. If the player has a deformity 


292 


J. Louisiana State M. Soc. 


MEDiCAL GRAND ROUNDS — Earl K. Long Memorial Hospital 


here and the clavicle rides high, then 
it is pretty obvious it is more than an 
A/C strain. 

Now, we do something on the side- 
line that many of the books tell you is 
not a good idea; but it does help. When 
a player comes out and complains about 
his shoulder and he has his shoulder 
pad and his jersey on, we attempt to put 
our hand up under the shoulder pad 
and palpate the acromioclavicular joint. 
We can feel the deformity and actually 
can reproduce a deformity by motion of 
the shoulder; and the player will let you 
know that it is very uncomfortable. The 
common things that we see are contu- 
sions of the shoulder, A/C strain, and 
acromioclavicular separation. If it is a 
separation, the player is a candidate for 
a repair job; and it should be done 
early. 

The other thing we see is a dislocation 
of the shoulder. The player can tell you 
if it is dislocated. He comes out with 
his arm flexed and held against his side, 
and any motion at all causes pain. He 
usually has a prominence anteriorly and 
just below the clavicle. If there is any 
doubt, at all, we take the jersey off, 
take the shoulder pads off, and make 
certain of what he has. Frequently the 
player has only a contusion, and he will 
be able to go back into the game. 

The next thing we see is a fracture of 
the clavicle. This is rather infrequent in 
college players, because they are usually 
in better condition. High school players 
will have a broken clavicle or a fracture 
just proximal to the acromioclavicular 
joint. 

Dr. Gehringer: Dr. Stander, would 

you discuss briefly the more common 
knee injuries seen in contact sports? 

Dr. Stander: Contusions of the knee 
are common. We see this usually in the 
“backs.” The way to check for contu- 
sions is to palpate and look at the knee. 
Any tender area with swelling usually 
indicates contusion. This diagnosis is 
made by exclusion of more serious in- 


juries, the most common being liga- 
mentous injury, usually of the medial 
collateral ligament. We check for this 
by palpating the proximal attachment 
of the medial collateral ligament. If 
there is tenderness, our suspicion is 
aroused. Tenderness right over the joint 
is more commonly associated with car- 
tilage injury, but may be ligament in- 
jury. 

Next, we check for stability by at- 
tempting to force the knee into a knock- 
kneed position to see whether there is 
abnormal motion and compare this with 
the opposite extremity. If the motion in 
the injured knee is greater than the un- 
injured knee, then we diagnose liga- 
mentous injury. It may be a strain de- 
pending on the amount of abnormal mo- 
bility. If he has instability (a small 
amount of increased motion) he may 
have a partial tear or a sprain. Fre- 
quently immobilization for a few weeks 
and a rehabilitation program will have 
corrected this problem. We always look 
for abnormal motion in the cruciate liga- 
ment by pulling the leg forward on the 
thigh. If we elicit what we call an an- 
terior draw sign (the leg comes forward 
abnormally as compared with the op- 
posite) then there is an anterior cru- 
ciate tear. 

Now, what is called the unhappy triad 
is a tear of the medial collateral liga- 
ment, the anterior cruciate ligament and 
the medial meniscus. When that occurs 
the patient should be scheduled for sur- 
gery early, very early. Swelling occa- 
sionally will mask some of the damage 
and makes repair more difficult. The 
results are not nearly as good as when 
the surgery is done early. 

Dr. Gehringer: Let me ask you a spe- 
cific question. Suppose this happens in 
Kentwood at 10:00 pm. You are pretty 
sure a player has a torn ligament, and 
you are 65 miles from Baton Rouge. How 
would you, as an orthopedic surgeon, 
like to be notified ? When would you 
like to see the player? How soon? How 


August, 1974 — Vol. 126, No. 8 


293 


MEDICAL GRAND ROUNDS— Earl K. Long Memorial ^Hospital 


would you like the family physician to 
care for this patient? 

Dr. Stander: Well, he should be put 
to bed and have applied compression 
bandage with ice on it. Give him some- 
thing for pain. I think if you put ice 
on it with a compression bandage, you 
will control the swelling until he can be 
seen by an orthopedist in the morning. 

Dr. Gehringer; Dr. Broussard, how do 
you apply ice packs with a compression 
dressing to an injured knee? 

Dr. Broussard: We like to cover the 
whole knee with ice. We take a six inch 
ace bandage, and wet it. We go around 
the knee once with pretty good com- 
pression. We apply ice bags still using 
good firm pressure. Whenever firm pres- 
sure is used, you need to check the limbs 
at least every hour for circulatory im- 
pairment. 

Dr. Gehringer: Do you release the 

compression every hour and tighten it 
again ? 

Dr. Broussard: Yes, five minutes are 
enough. Always rewrap the knee with 
compression. Compression with ice bags 
also makes a good splint. Of course, we 
use post-op splints a good bit, but this 
does produce good immobilization. 

Dr. Gehringer : Thank you. Dr. Brous- 
sard. Dr. Stander, because the ankle is 
very commonly injured in sports, we 
would like you to describe some of the 
problems related to this area. 

Dr. Stander : The ankle isn’t the most 
serious; but it is the most commonly in- 
jured. Most frequently we see a sprained 
ankle. On the sideline, we palpate the 
lateral malleolus, which is the side most 
frequently injured. If the tenderness is 
high on the malleolus then we suspect 
a fracture. Tenderness between the tip 
of the malleolus, or where the ligaments 
are, usually indicates a sprain. We ro- 
tate and move the ankle to elicit instabil- 
ity. If there is any abnormal motion or 
undue pain, we must decide whether the 
sprain is sufficient to keep the player 
out of the game. Frequently strapping 


or an ankle wrap will permit him to 
walk. If he walks comfortably, we let 
him jog. If he can jog comfortably, we 
let him sprint, and if he can do this 
without pain or limp, we let him go back 
into the game. 

Dr. Gehringer: I would like to ask 

the panel to comment briefly about the 
use of Xylocaine in bruises and tendon 
strains, in order to make the player more 
comfortable and allow him to return to 
the game. 

Dr. Stander: That is contraindicated. 
We use Xylocaine, Wydase, and some- 
times steroids in joints but not in liga- 
ments. If we see a young athlete a week 
after injury and he has swelling and 
other evidences of chronic sprain, we 
may aspirate several cc’s of joint fluid 
and replace with Wydase. This treat- 
ment will allow him to have a more com- 
fortable rehabilitation. 

Dr. Gehringer: We would like to open 
the panel to questions from the audi- 
ence. 

Dr. James Christopher Would you 
please say something about myositis os- 
sificans? 

Dr. Stander: The best treatment, of 
course, is prevention. Myositis ossificans 
is most commonly seen in the lateral as- 
pect of the arm or on the thigh. Any- 
time a player has a hematoma, which is 
a precursor of myositis ossificans, we use 
a good bit of enzymes, usually Wydase; 
we aspirate the hematoma and use ice 
and compression. 

If a player develops myositis ossifi- 
cans, the area will require additional 
padding. Excision of myositis ossificans 
is indicated only when it interferes with 
joint function. Occasionally you may see 
large ossifications that predispose the 
player to re-injury and these may be ex- 
cised ; but for all practical purposes, they 
aren’t removed unless they interfere with 
joint function. 

Dr. Gehringer: I understand there are 
some coaches and trainers in the audi- 


(®)New Roads, Louisiana. 


294 


J. Louisiana State M. Soc. 


MEDICAL GRAND ROUNDS — Earl K. Long Memorial Hospital 


ence; I would like to invite their ques- 
tions. 

Ted Jambon:^^^ I have had about 
three cases of Osgood-Schlatter’s disease. 
The doctors I have taken the boys to 
have given me what appear to be con- 
flicting stories about what causes it, and 
how to treat it. I would like to hear 
some comment from the panel on this 
disease. 

Dr. Stander: It is rarely necessary to 
do anything about Osgood-Schlatter’s 
disease. We have tried injecting steroids, 
but we haven’t found much beneficial 
effect. In cases where it is very bother- 
some, or severe, we immobilize the pa- 
tient. In most instances, protection and 
limited activities for several weeks, along 
with some physical therapy (such as 
heat or whirlpool) are usually sufficient. 

Faimon Roberts I would like to ask 
Dr. Broussard what he does for the com- 
mon “hip pointer” on the field when it 
happens, and then during the next 
week ? 

Dr. Broussard : Just as soon as it hap- 
pens, we like to get ice and compression 
on it, that is, at least for 24 hours. The 
second day we start giving light heat, 
low ultrasound, and steam packs. Be- 
cause there is very little tissue there, we 
haven’t been very successful with deep 
therapy like diathermy. We use whirl- 
pool. We give the players oral enzymes, 
and Dr. Stander has injected steroids 
into the localized area with good results. 

Dr. Stander: This is one place where 
we do use the steroids on occasion, and 
do get very good results. We do not 
think we can hurt the player by inject- 
ing the iliac crest, and the results are 
frequently very rewarding. 


(f) Trainer, McKinley Senior High, Baton 
Rouge. 

(s) Coach, Capitol High School, Baton Rouge. 


Dr. Trent James I’d like to find 
out what might be the consensus of the 
group concerning physical examination 
given to athletes by their family doc- 
tors in their office versus examination 
that might be given within the training 
area at school, en masse. Any opinions ? 

Dr. Stander : I think if the family phy- 
sician does a good examination it is very 
beneficial. Family physicians may know 
of some illness or injury that the player 
has had that the examining team doc- 
tor is not aware of. We do a cursory 
examination, but we also have a his- 
tory. A family physician’s report is very 
helpful, but I don’t believe it is a sub- 
stitute for the screening we do. 

Dr. Gehringer: I feel very much the 
same way. I think the family physician 
has a great deal to offer if he sends a 
good history and physical to the athletic 
department. 

Editor’s Note : The constantly expand- 
ing athletic programs in schools make 
seminars, such as the foregoing, ex- 
tremely important. The participants are 
to be commended for their fine practical 
expositions. Dr. James’ question focuses 
attention on the need for care in per- 
forming and in recording the history and 
physical examination in the physician’s 
office. The overworked physician, bur- 
dened with the problems of many sick 
patients, often resents the need to de- 
vote time to the examination of a seem- 
ingly healthy young man. Dr. Stander 
properly emphasizes that the physician 
who knows the young athlete may well 
warn him and the athletic team doctor 
that even minor physical abnormalities 
may greatly increase the liability of seri- 
ous athletic injuries. As in so many other 
aspects of the practice of medicine, the 
personal attending physican, here plays 
a great role. 

(ii) Baton Rouge. 




August, 1974 — Vol. 126, No. 8 


295 


Guest Gditoeiui 

The Family Doctor 


In 1966, a rapid succession of reports 
emphasized the need for the health in- 
dustry to provide comprehensive per- 
sonal health service of high qualityd'^ 
These reports also acknowledged that 
general physicians are the key profes- 
sional personnel in providing and co- 
ordinating medical services for individ- 
uals and for the family. Such a person 
needs to possess a basic core of knowl- 
edge in all areas of medicine and must 
maintain this knowledge current through 
constant use. Learning opportunities have 
for long been lacking in emphasis on pri- 
mary care except for the limited tours of 
duty in the Emergency Room. While 
important, these experiences because 
they are episodic miss much of the pri- 
mary care content of health needs as 
seen in the ambulatory care setting of 
the physician’s office. Family physi- 
cians represent, by far, the largest group 
of health care specialists in primary 
care. In numbers, they represent al- 
most 50 percent of the physicians in- 
volved in patient care. 

In February of 1969, a primary cer- 
tifying board in family practice was ap- 
proved. Since then, there have developed 
203 approved training programs, 82 of 
which are university affiliated. It is 
interesting to note that first year posi- 
tions are currently 86 percent filled. In 
1973, there were 5,477 applicants for 
first year positions. There are present- 
ly 5,809 diplomates of the American 
Board of Family Practice representing 
a large and rapidly growing group of 
health professionals dedicated to pri- 


* Dr. Sanchez is the associate dean for con- 
tinuing medical education, LSU School of Medi- 
cine, New Orleans. 


Specialist in People 

RAFAEL C. SANCHEZ, MD* 
New Orleans 

mary care and to the new concepts of 
family practice. 

The modem medical school is cur- 
rently experiencing the intense impact 
of this situation. Pressures are currently 
being applied on medical schools from 
a variety of sources to restructure their 
organizational and instructional pat- 
terns. Such restructuring is aimed at 
making the medical school experience 
more meaningful, more relevant, and 
hence more conducive to producing phy- 
sicians capable of rendering high qual- 
ity medical care in a medical and social 
climate characterized by constant flux 
and increasing complexity. 

Some schools have as yet failed to 
respond to this challenge. Many others 
are currently in the process of intense 
self-study and cautious self-assessment. 
Some have already drastically altered 
their organizational structure and cur- 
ricula and are currently experimenting 
with a variety of highly innovative edu- 
cational programs. 

There is no doubt that the modern 
medical school should be carefully scru- 
tinizing the product it produces and the 
process whereby the product is chosen 
as well as produced. Medical education- 
al programs of an innovative and ex- 
perimental nature also should be en- 
couraged and evaluated. 

At the LSU School of Medicine in 
New Orleans there has been an inten- 
sive effort to deal with these problems : 

— Students are introduced to the con- 
cept of family medicine in their fresh- 
man year by lectures by family doc- 
tors. 

— A preceptorship program provides 
exposure to family practice settings. 


296 


J. Louisiana State M. Soc. 


GUEST EDITORIAL 


Last year, 49 medical students took part 
in this program. 

— Two residency programs are now 
approved and operative, training 24 
residents in Baton Rouge and Lake 
Charles. Another is being developed in 
Bogalusa. 

— The number of students expressing 
interest in family practice has increased 
from 16 percent in 1969 to 30 percent 
in 1974. 

Yet, more needs to be done. 

The selection process of students 
needs to be reviewed with the goal of 
selecting students more likely to return 
to rural settings. 

Incentive programs such as student 
loans need to be carefully developed. 

In order to overcome the emerging 
physician’s fears of isolation or separa- 
tion from the authoritative reassurance 
of the paternal medical center, a strong 
continuing education effort needs to be 
undertaken and developed. This can be 
done by exposure and better utilization 
of the Louisiana Hospital Television Net- 
work. 

Communities should be encouraged to 
develop incentive programs of their own. 


Sponsorship of a selected student would 
be helpful. Community representatives 
should be encouraged to come to the 
medical center to sell students on their 
community. 

Medical schools need to develop a 
greater sensitivity to the primary care 
needs of the state. Community hospitals 
should be encouraged and subsidized in 
the development of family practice resi- 
dencies and other primary care pro- 
grams. 

Perhaps most important, the medical 
profession must give realistic support to 
developing family practice programs. 
Support that acknowledges the fact that 
the modern family physician is indeed 
a people specialist. 

References 

1. The core content of family medicine. A report of 
the American Academy of General Practice Committee on 
Requirements for Certification, GP (Nov) 1966, Vol. 
XXXIV, No. 5 

2. Meeting the challenge of family practice. The re- 
port of the Ad Hoc Committee on Education for Family 
Practice of the AMA Council on Medical Education (Sept) 
1966 

3. The graduate education of physicians. The report 
of the Citizens Commission on Graduate Medical Educa- 
tion, commissioned by the American Medical Association, 
pub. August, 1966 

4. Health is a community affair. Report of the Na- 
tional Commission on Community Health Services, pub. 
Harvard University Press, Cambridge, Massachusetts, 
1966 



ELUCIDATION 


PA view of the chest on admission 
showed cardiac enlargement with a 
right infra-hilar mass in the posterior 
aspect. The possibility of tumor of the 
lung was strongly considered. Subse- 
quent studies after fluoroscopy and bari- 
um swallow showed the mass to be a 
markedly enlarged left auricle which 
decreased in size following treatment. 


The patient was found to have aortic 
stenosis and mitral insufficiency with 
consequent enlargement of the left 
atrium. 

A mistaken diagnosis of tumor of the 
lung could have been made without 
proper clinical data. This emphasizes 
the need for the attending physician to 
provide adequate information or to con- 
sult with the radiologist before any 
meaningful interpretation of x-ray 
studies can be made. 


August, 1974 — Vol. 126, No. 8 


297 



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J 


298 


J. Louisiana State M. Soc. 




ocioeconomic 


• • 



By LEON M. LANGLEY, JR. 


Virtually All Medical School Graduates would be obligated to seiwe in manpower 
shortage areas for two years under one of two health manpower bills pro- 
posed by Sen. Edward Kennedy (D. Mass.). The Health Professions Educational 
Assistance Act of 1974 (S3585) would also require periodic relicensure of 
physicians and nationwide licensure standards. The legislation would require 
the secretary of HEW to certify all residency programs with respect to the 
allocation of medical specialties. Under this system, more physicians would 
be directed into primaiy care fields. Loan forgiveness for students receirtng 
aid under the progi'am would be 50 percent for the first year and 50 percent 
for the second year of seiwice in shortage areas. Capitation gi’ants would 
continue to be provided to medical schools and schools of public health, pro- 
vided all enrollees agree to serve in the National Health Service Corps or in a 
shortage area. 

New Guidelines for the production of drug abuse prevention materials are now 
available from the Special Action Office for Drug Abuse Prevention, Wash- 
ington, D. C. 20506. Previous guidelines had been criticized as counter-pro- 
ductive. The new guidelines exclude messages that make fear the main deter- 
rent to drug use and stress the complexity of the drug problem. To support 
the implementation of the guidelines, the National Institute on Drug Abuse 
is offering a free pre-testing seiwice to those who need assistance in deter- 
mining accuracy and audience-acceptability. Contact Ms. Jean McMillen, Na- 
tional Institute on Drug Abuse, Parklawn Building, Rm. 8C09, 5600 Fishers 
Lane, Rockville, Md. 20852, to have materials pre-tested. 

Action Plem for Physician Recruitment is a new information packet published by the 
AMA’s Physicians’ Placement Service. The free 11-page booklet and supple- 
mentaiy materials explain the how-to’s of recruiting and retaining MDs in 
small towns and rural communities. Copies of the packet and information on 
registration \vith the PPS are available from Physicians’ Placement Seiwice, 
AMA Headquarters. 

The Medical Liability Commission has named its first executive director, Frederic 
N. Andre, and plans to open an office in Chicago by July 1. Activities of the 
commission will center on patient safety, provider qualifications, data collec- 
tion, legal doctrines and liability insurance. Andre is presently Louisiana’s AMA 
field representative. The location of the commission’s Chicago office will be 
announced soon. 

Environmental Quality and Food Supply, a new AMA book, says that there is a 
gi'eater health risk from mass staiwation than from pesticides and chemical 
fertilizers. The authors call for a reordering of priorities to seek solutions to 
the environmental and food supply problems, so that continued high production 
can be maintained T\dth a minimum of damage to the environment. The book, 
an outgi'owth of a 1972 AMA symposium, is available for $13.95 from the pub- 
lisher, Futura Publishing Co., 295 Main St., P. O. Box 298, Mount Kisco, N. Y. 
10549. 


JL -=^ 


August, 1974 — Vol. 126, No. 8 


299 


a 


r^ aniza 


lion Section 


The Executive Committee dedicates this section to the members of the Louisiana State 
Medical Society, feeling that a proper discussion of salient issues will contribute to the 
understanding and fortification of our Society. 

An informed profession should be a wise one. 


LSMS MEETING NOTICE 

A meeting of the Executive Committee of the 
Louisiana State Medical Society will be held on 
Thursday, October 24, 1974, beginning at 9:00 
a.m., at the Society headquarters. 


HIGHLIGHTS OF HOUSE OF 
DELEGATES ACTIONS 
AMERICAN MEDICAL ASSOCIATION 
123rd ANNUAL CONVENTION 
CHICAGO, ILLINOIS 

A change in the method of electing AMA 
trustees, a definitive policy statement on PSRO’s, 
the need for additional safeguards to preserve 
the confidentiality of medical records, and new 
recommendations which affect the relationship 
between hospitals and hospital medical staffs 
were among the important items approved by 
Delegates at the 123rd Annual Convention in 
Chicago. 

Meeting for a total of 19 hours and 38 min- 
utes, the House acted on 66 reports and 137 res- 
olutions for a total of 203 items of business. 

The House approved bylaws changes which re- 
place the “slot method” of electing trustees by 
the “simultaneous election of candidates to sev- 
eral positions of equal rank,” in which all can- 
didates run for board vacancies on a single 
ballot. 

Under the new method, trustees for full, three- 
year terms are elected first, followed by the 
selection of trustees to fill unexpired terms. 
Election of the AMA president-elect, vice-presi- 
dent, and speaker and vice-speaker of the House 
remains on a separate basis. 

Delegates selected Max Parrott, of Portland, 
Ore., as president-elect. 

Elections 

In addition to Dr. Parrott, others elected or 
re-elected to positions in the Association were: 

Vice-President: Joseph M. Ribar, Alaska 

Speaker of the House: Tom E. Nesbitt, Ten- 
nessee (re-elected) 

Vice-Speaker of the House: William Y. Rial, 
Pennsylvania (re-elected) 

Trustees, for 3-year terms: Daniel Cloud, Ari- 
zona; James M. Blake, New York; Hoyt D. Gard- 
ner, Kentucky; Raymond T. Holden, District of 


Columbia (re-elected). For the unexpired two- 
year term of James H. Sammons, AMA executive 
vice president-designate, Frank J. Jirka, Illinois, 
and for the unexpired one-year term of Dr. 
Parrott, Joe T. Nelson, Texas 

Judicial Council: Samuel R. Sherman, Califor- 
nia, succeeding Charles C. Smeltzer, Tennessee 

Council on Constitution and Bylaws: Urban H. 
Eversole, Massachusetts, succeeding Robert Mayo 
Tenery, Texas; Herman J. Smith, Iowa, succeed- 
ing Dr. Cloud, elected a trustee 

Council on Medical Education: Richard G. 
Connar, Florida, succeeding William A. Sodeman, 
Pennsylvania; Joseph White, Jr., Pennsylvania, 
re-elected; Charles Verheyden, Minnesota (intern- 
resident member), succeeding Louis W. Burgher, 
Minnesota 

Council on Medical Service: John G. Morrison, 
California, succeeding John M. Rumsey, Califor- 
nia; Paul W. Burleson, Alabama, re-elected; 
Robert T. Kelly, Minnesota, succeeding Hector 
W. Benoit, Jr., Missouri; Douglas Hiza, Iowa 
(intern-resident member), succeeding Daniel 
Ostergaard, Minnesota 

Address of Vice President of the 
United States 

Addressing the House on Tuesday, June 25, 
Vice President Gerald Ford advocated some 
form of national health insurance, but warned 
that in the process of its development, there 
should be no further erosion of patient confi- 
dentiality. 

Though it had been rumored that Ford would 
address the PSRO issue, his only passing refer- 
ence was: 

“I’ve been getting a lot of free advice lately 
on how to run my business. I have not neces- 
sarily followed this advice. So, I won’t give you 
any free advice on how to run your business. In 
my view on PSRO, (p) oliticians (s)hould 
(r)emain (o)ut of it.” 

Returning to his text, the vice president as- 
serted that with the vast resources of the nation, 
there is “no excuse for a single American to be 
deprived of the finest treatment available.” 

Ford said a national health insurance program 
is necessary because of the prohibitive costs of 
catastrophic illnesses and the need to more ef- 
fectively use and distribute medical resources. 
While declaring the physician should work for his 


300 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


patients and “not for the bureaucrats in Wash- 
ington,” he added that the “government must do 
for the individual citizen what he cannot do for 
himself.” 

Among the NHI proposals mentioned by the 
vice president were the Administration’s own 
plan, the Kennedy-Mills measure, and the AMA’s 
Medicredit concept, for which he offered congrat- 
ulations to the AMA “for its constructive atti- 
tude.” He added that in the NHI discussion, “the 
AMA is not the problem but a part of a solution 
to the problem.” 

Ford said even with the diversity of NHI pro- 
posals in Congress, there is “a willingness to com- 
promise,” and added that he personally favors a 
“free enterprise approach involving private and 
voluntary philosophies.” 

The vice president asked that physicians be 
willing to participate in effecting some sort of 
NHI compromise during the present Congress, 
“instead of an abdication to those who would 
impose a dogmatic formula through a ‘veto-proof’ 
Congress they hope to elect come Nov. 5, 1974.” 

Turning to confidentiality. Ford said that while 
ways must be found to minimize federal involve- 
ment in health care delivery while achieving an 
effective private/public health care partnership, 
it is essential that we avoid bureaucratic inter- 
vention between the doctor and his patient — 
intervention that compromises the rights and pri- 
vacy of both.” 

Inaugural Address: 

Malcolm C. Todd, President of AMA 

In his inaugural address on Wednesday, June 
26, Dr. Malcolm C. Todd, the new AMA presi- 
dent, urged the AMA to sponsor the development 
of a “national policy on health” to place needs 
and goals in focus. 

He said “a tremendous amount of confusion” 
exists on the health-care scene and is reflected in 
plans being advanced in Washington and else- 
where. 

“It is high time to put the Health Care State 
of the Union into its true perspective, before lack 
of perspective leads to waste of effort, waste of 
money, waste of hope,” he said. 

Dr. Todd asked the delegates to consider spon- 
soring a National Academy of Health to formu- 
late his proposed national policy. The academy, 
he said, would give both private and public sec- 
tors of health care “an open forum and frame- 
work in which to exchange views, pinpoint health 
care needs, evaluate total health care resources, 
and arrive at some common sense of purpose, 
with sound programs, goals and priorities.” 

Dr. Todd noted a national policy on health also 
is called for in Congressional bills that would 
make health services a public utility. Under one 


such proposal, a five-man federal commission 
would make policy recommendations. 

Such a policy would be “destructive,” he said, 
unless the private sector of care seizes the initia- 
tive in formulating it. 

His speech — which followed his installation as 
the 129th president of the AMA — also urged the 
association to : 

— “Make everyone aware that we are for na- 
tional health insurance as needed,” and have our 
own NHI Bill, Medicredit, in Congress. 

— Organize the development of guidelines to 
protect the privacy of patient information accu- 
mulated in computerized health care centers. No 
inherent right of the patient “is greater — or 
presently more imperiled — than what he tells his 
doctor,” Dr. Todd said. 

— Assume a “new and strong coordinating 
role” in medical education, partly so that it will 
give more attention to human concern for pa- 
tients. “If the AMA is to be held accountable 
for what our profession does, then it must insist 
upon more responsibility for the manner in 
which our profession is trained.” 

— Establish a “university without walls,” to 
confer an advanced academic degree, stimulating 
more physicians to enroll in continuing education. 

— Develop nationwide proposals for arbitration 
and no-fault procedures in malpractice cases, to 
curb the serious impact of these cases on health 
care costs. 

Emphasizing that organized medicine “must 
also be organized concern,” Dr. Todd said: “The 
people of America are looking at us, and I want 
them to see an AMA that is committed to serving 
all of them.” 

Final Remarks to the House: 

Russell B. Roth, AMA President 

There are new and welcome political awaken- 
ing and a new activism within the ranks of medi- 
cine, according to Russell B. Roth, president of 
the AMA, who gave his final report to the House 
Sunday, June 23. 

This rise in political activism — generated by 
various federal and other third-party health care 
proposals — comes none too soon. Dr. Roth said, 
citing the rising health-care activism among poli- 
ticians. 

Health care “offers unique attractions” to 
politicians who, with minimal risk, can crusade 
for the avowed “right” of every American to 
health care, he added. Because while politicians 
are blamed for blunders in most national and for- 
eign affairs, “it’s the doctors, the hospitals and 
the insurance companies who catch all the heat 
for problems in the health care field,” Dr. Roth 
pointed out. 

Yet both the public and the politicians are 


August, 1974— Vol. 126, No. 8 


301 


ORGANIZATION SECTION 


A powerful lot of people 
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unable to differentiate between good medicine 
and “the fakes, the phonies and the frauds on 
the fringe of medicine,” he said. 

Dr. Roth cited as “a curious exercise in funda- 
mental ignorance” the inclusion by some states 
of chiropractic services under Medicaid, one 
state’s legalization of acupuncture, and federal 
legislators who favor rigid quality controls over 
physicians and osteopaths but agree to pay for 
chiropractic services in the same piece of legis- 
lation. 

It is against this background, he said, that Con- 
gress now wrestles with various NHI proposals, 
a fact that could make 1974 a banner year for 
the politically ambitious. But Dr. Roth warned 
physicians against total preoccupation with pro- 
posed health legislation, citing problems which 
confront the profession from within its own 
ranks. 

Just as he did a year ago in his inaugural ad- 
dress, Dr. Roth expressed concern over the lack 
of a unifying theme of action in medicine. While 
the profession has been “prodded into activity,” 
he said, it is “at the moment an uncoordinated 
activity with much thrashing and flailing about 
and a tendency to charge off in diverse direc- 
tions . . .” 

In fact, the need for a unified defense of pro- 
fessional freedoms may be the greatest challenge 
facing medicine’s leadership. Dr. Roth said. The 
AMA is moving to meet this challenge, he said. 
Referring to the AMA’s long-range planning pro- 
gram, Dr. Roth concluded that: 

“As yet there is nothing at which to point with 
pride; but there is a plan emerging which bids 
fair to keep the AMA as the one great respon- 
sible organization in defense of the principles of 
medical practice which we would like to be- 
queath to our successors.” 

Summary of Actions of the 
House of Delegates 

Because of the wide-ranging nature of the 
actions taken by the House of Delegates, and for 
the sake of clarity, this summary will be divided 
into five subject areas with appropriate sub- 
headings as follows: 

Physicians and the Government; Physicians 
and Hospitals and Medical Schools; Physicians 
and the Public; Association and Internal Matters 
of the House; and Miscellaneous. (Note: The 
items mentioned under each subject are not all- 
inclusive, but include only the more significant 
actions taken.) 

Physicians and the Government 

PSRO’s — Speculation over possible changes in 
PSRO policy by the House dominated the atten- 
tion of those attending the convention, including 
the media. 


J. Louisiana State M. Soc. 



ORGANIZATION SECTION 


During its day-long hearing on Monday, June 
24, Reference Committee A considered 2 re- 
ports and 25 resolutions bearing on the issue, and 
estimated that 64 speakers addressed themselves 
to PSRO. 

But on Wednesday, the Delegates — cognizant 
of the hours of debate devoted to PSRO at Ana- 
heim last December and in New York City last 
June — overwhelmingly voted (202 to 24) to 
terminate debate after a few minutes. 

Then the House adopted a substitute resolution 
on PSRO proposed by the reference committee, 
whose members emphasized that the resolution 
provides the association with a “clear-cut, defini- 
tive position which cannot be misunderstood by 
anyone inside or outside this House of Delegates.” 
The resolution: 

— Instructs the Board of Trustees to seek con- 
structive amendments to the PSRO program, par- 
ticularly in potentially dangerous areas such as 
confidentiality, malpractice, development of 
norms, quality of care, and the authority of the 
Secretary of HEW. 

— Directs the AMA to continue efforts to 
achieve legislation which allows the profession 
to perform peer review according to established 
medical philosophy and the best interests of the 
patient. 

— Emphasizes that state associations which 
elect non-compliance with PSRO are not pre- 
vented from doing so by the new policy, but urges 
such associations to develop effective non-PSRO 
review programs embodying the principles en- 
dorsed by the profession as constructive PSRO 
alternatives. 

The new policy also provides that in the event 
that the PSRO program does, in fact, adversely 
affect patient care or conflict with AMA policy, 
then “the Board of Trustees (will) be instructed 
to use all legal and legislative means to rectify 
these shortcomings.” 

Extension of Policy on National Health Insur- 
ance — Two statements on national health insur- 
ance were adopted after lengthy debate. One 
calls on the Board of Trustees to cooperate with 
state associations “to attempt to devise mecha- 
nisms mutually acceptable to the private medical 
and insurance communities which will ensure the 
provision of health insurance coverage through 
the purchase of private health insurance, and to 
seek means to secure favorable Congressional and 
public support for their adoption.” 

During discussion, it was pointed out that the 
addition to the NHI policy does not affect AMA 
support for Medicredit, but is intended to stimu- 
late new health insurance mechanisms. The sec- 
ond resolutions calls on the AMA and component 
associations to work to detach “any national 
health insurance program from the controlling 
intrusion of existing PSRO laws and regulations.” 


Support for Drug Industry, Action on FDA — 
The House adopted two resolutions bearing on 
drugs. One directs the AMA to continue its sup- 
port of the pharmaceutical industry in efforts to 
develop and market pharmaceutical products 
meeting proper standards of safety and efficacy. 
The other resolution directs the AMA to “exert 
all efforts to amend or repeal the Kefauver- 
Harris” drug amendments of 1962, which gave 
the FDA broad new powers in drug manufactur- 
ing and marketing, and which critics of the FDA 
contend have tended to stifle the developing and 
marketing of new drugs in the United States. 

Oppose “Public Utility” Medicine — The House 
went on record as being opposed to certain bills 
in Congress which would replace the federal 
“Health Professions Educational Assistance Act” 
which expired June 30. Under the bills, compre- 
hensive health planning programs would be re- 
placed with public utility type bodies which would 
control certain aspects of health education and 
health care delivery, and medical licensure. An 
amended resolution adopted by the House directs 
the Board of Trustees to mobilize AMA member- 
ship in opposition to offensive sections of the pro- 
posed legislation, and take strong actions on other 
fronts. 

In other actions affecting physicians and the 
government, and other third parties, the House: 


Professionad 
treatment for 
professionad 
people. 



OLDSMOBILE 


VETERANS & CAUSEWAY 

"The dealership that's different': 


August, 1974 — Vol. 126, No. 8 


303 


ORGANIZATION SECTION 


— Directs the AMA to seek an extension of 
from 30 to 90 days to respond to proposed health 
regulations printed in the Federal Register, and 
that government agencies using the Federal Reg- 
ister for rule-promulgating purposes be urged to 
hold public hearings on the merits of proposed 
legislation. 

— Calls on the AMA to oppose the concept of 
claims rejection on the basis of “diagnostic admis- 
sion” or “lack of medical necessity” without prior 
physician notification, and to recommend a peer 
review mechanism be established independent of 
the third-party carrier to review claim conflicts 
with such mechanisms to be established by exist- 
ing medical foundations, medical societies or other 
independent peer review organizations. 

— Requests the AMA to work with third par- 
ties to secure increased acceptance of the AMA 
uniform health insurance claim form, and urges 
state associations to encourage acceptance of the 
form by insurance commissioners, and, if neces- 
sary, through state legislation. 

— Urges continued AMA efforts to prevent fu- 
ture imposition of government fee controls, and 
opposes the mandatory imposition of a “Health- 
card” as the payment mechanism under the Ad- 
ministration’s national health insurance plan, and 
instead, reaffirmed the right of the physician to 
bill patients directly. 

Physicians and the Public 

Confidentiality of Patient Records — The House 
adopted two reports bearing on confidentiality of 
medical records. Report I of the Council on Med- 
ical Service describes a wide-ranging series of 
proposals to enable the medical profession and in- 
surance companies to “maintain the confidential- 
ity and security of patient information.” Report 
S of the Board of Trustees notes that the Council 
on Legislation is developing model legislation as 
a guide to possible state legislation to preserve 
confidentiality, and that a model bill should be 
ready for consideration by the House at the 1974 
Clinical Session in Portland, Oregon. 

Health Insurance for Migrant Workers — Dele- 
gates supported in principle a report from the 
Council on Medical Service for the development 
of a nationwide health insurance program for 
migrant workers. The report drew some concern 
about safeguards for the medical records of mi- 
grants. The report was referred to the Board of 
Trustees for development of appropriate legisla- 
tion. 

Transport of Radioactive Material via Air- 
lines — The House put the AMA on record as rec- 
ommending that the shipment of radioactive ma- 
terials for medical use via airlines be shipped 
“under strictly enforced, existing federal regula- 
tions which guarantee the actual low potential 
hazard” of such materials to passengers and 


crews, and directed that the recommendation be 
presented to appropriate federal agencies for 
implementation. 

In other actions affecting physicians and the 
public, the House directed that; 

— The new national blood policy be privately 
implemented through the appropriate organiza- 
tion of the AMA, state and county medical so- 
cieties and their committees on transfusion. 

— -The AMA continue to inform the public and 
the profession of the potential problems and risks 
in permitting the non-physician substitution of 
drugs of choice prescribed by physicians, and 
that state associations support this position be- 
fore state legislatures considering laws which 
would allow drug substitutions. 

— The AMA endorse use of the condom as one 
of the effective methods of venereal disease con- 
trol. 

Physicians and Hospitals and 
Medical Schools 

Report on Physician-Hospital Relations, 197 A — 
The House adopted the 104-page “Report on 
Physician-Hospital Relations, 1974,” compiled by 
the Council on Medical Service and its Commit- 
tee on Private Practice. An update of an earlier 
report made in 1964, the 1974 version contains 14 
specific recommendations to cope with problems 
developing between some hospitals and their med- 
ical staffs. Among other things, the recommenda- 
tions are aimed at protecting medical staffs 
against unilateral action by hospital governing 
boards relative to staff bylaws, rules and regu- 
lations. 

Students, Interns & Residents — Two informa- 
tional reports dealing with possible guidelines for 
housestaffs in developing contracts in institutions 
in which they serve generated considerable dis- 
cussion before Reference Committee C. Among 
those testifying were medical students, residents, 
faculty members, hospital directors and members 
of the AMA’s Board of Trustees and Council on 
Medical Service. Because of the importance and 
the complexity of the issues involved, the two re- 
ports, plus a revised report submitted by the 
Intern and Resident Business Session during the 
convention, were referred to the Board of Trus- 
tees for further study and consultation with ap- 
propriate groups. Delegates directed the Board 
to report back at the 1974 Clinical Session. 

The House adopted a resolution calling for the 
AMA, through appropriate committees and coun- 
cils, to assure due process for medical students, 
and requested a further report at the next Clin- 
ical Session. 

Another resolution proposing guidelines for 
“Fair, Professional Relationships between Train- 
ing Institutions and House Officers” (intended 
for inclusion in the essentials of approved intern- 


304 


J. Louisiana State M. Soc. 


ORGANIZATION SECTION 


ships, and residencies) was referred for further 
study and report back at the Clinical Session. 

The House adopted a resolution calling on the 
AMA to encourage — and urging medical schools 
to implement — a series of lecture programs for 
students on the socio-economic aspects of medi- 
cine. 

New Liaison Committee on Medical Education 
— Delegates adopted Board of Trustees Report I 
calling for the establishment of a new Liaison 
Committee on Continuing Medical Education. 
Structure and duties of the new committee have 
been worked out by AMA representatives and 
those representing the American Board of Medi- 
cal Specialties, the American Hospital Associa- 
tion, the Association of Medical Specialties, and 
the Council of Medical Specialty Societies. 

In other actions, the House; 

— Supported a moratorium on the licensure of 
allied health occupations until the end of 1975. 

— Adopted a report containing “Essentials of 
an Accredited Educational Program for the Sur- 
geon’s Assistant.” 

— And reaffirmed the AMA’s opposition to 
blanket pre-admission certification of hospital pa- 
tients by governmental or hospital edict. 

— Adopted a resolution urging the AMA to sup- 
port the development of preceptor programs in 
primary patient care to stimulate the production 
of more primary care physicians. 

Association and Internal Matters 
of the House 

Specialty Representation in the House: In re- 
sponse to proposals to increase specialty repre- 
sentation in the House, the Reference Committee 
on Constitution & Bylaws reported extensive tes- 
timony, and urged “all concerned parties to in- 
crease communication, cooperation and liaison” to 
resolve the complex question. 

The House adopted the reference committee re- 
port, and referred report H of the Board of Trus- 
tees containing proposed modifications for spe- 
cialty representation in the House to the Council 
on Constitution and Bylaws for inclusion in its 
continuing study. 

Malpractice Problems — A resolution calling on 
the AMA and constituent societies to “institute 
a nationwide public education program to inform 
the public” of malpractice problems, and for the 
AMA to “spearhead state and federal legislation” 
to correct malpractice inequities, was referred to 
the Board of Trustees and its Committee on In- 
surance for report back at the 1974 Clinical 
Session. 

Membership Opinion Polls — The House con- 
curred in recommendations to reconstitute the 
Committee on Membership Opinion Polls as a 
Special Committee of the House, and authorized 


future polls of membership opinion subject to 
approval of the Board of Trustees. 

In other internal matters, the House: 

— Requested changes in the constitution and 
bylaws to permit additional scientific sessions on 
a regional basis (to supplement the programs at 
the annual and clinical sessions) so the House can 
take affirmative action on the proposal at the 
1974 Clinical Session. 

— Instructed the Board of Trustees to distrib- 
ute to each delegate, alternate delegate and con- 
stituent state association a summary of actions 
taken at each meeting of the Board. 

Miscellaneous Actions of the House 

In miscellaneous actions, the House: 

— Adopted a resolution to amend the bylaws to 
make past AMA vice-presidents ex-officio mem- 
bers of the House (without voting privileges). 

— Rejected the establishment of a nominating 
committee for councils of the House. 

— Changed the name of the Section on Plastic 
and Reconstructive Surgery to the “Section on 
Plastic, Reconstructive, and Maxillofacial Sur- 
gery.” 

— Stipulated that Board reports nominating 
members of the Council on Medical Education 


WANTED 

An Internist and a Family Practice Physician by 

nine man group in 60,000 population community 
in Central Louisiana. Excellent new hospital facili- 
ties. Group consists of general surgery, Ob-Gyn, 
family practice and internal medicine. Salary for 
the first year negotiable, partnership to follow. 
Liberal fringe benefits. Sub-specialty in cardiology 
or pulmonary disease useful but not necessary. 

Contact T. W. Davis, M.D. or W. H. Brown, M.D., 
Area Code 318, Phone 445-4513, 830 DeSoto 
Street, Alexandria, Louisiana 71301. 


FOR SALE 

Okay, so you missed out on the first two offers 
for a golden opportunity, so here's your last chance! 

General Practice, property 150 x 120, building 
2500 sq. ft., equipment including 300 M.A. G.E. 
with fluoroscope and spot film, EKG, Birtcher 
Megason XII, U.V. lamp. Uni-meter, etc., sacrifice 
at $50,000. New 50 bed capacity hospital opening 
in community 2nd Oct. Owner joining E.R./Resi- 
dent Staff group for same. Your admissions will 
be adequately cared for in your absence. Within 
one hour commuting of New Orleans or Baton 
Rouge. 

Contact C. R. Daunis, M.D. 1-504-265-4236; 
Vacherie, La. 70090. 


August, 1974 — Vol. 126, No. 8 


305 


ORGANIZATION SECTION 


contain a breakdown of current members’ status 
to ensure a proper balance between fulltime edu- 
cators and private practitioners. 

— Rejected a resolution which called upon the 
AMA to encourage individual states to carry out 
referenda on the question of prohibiting the sale 
of handguns, but the House reaffirmed the 1973 
policy that the AMA “urge the enforcement of 
strict penalties for the use of firearms in the 
commission of a crime.” 

— Rejected a proposal that AMA delegates be 
chosen by popular election within their respective 
state medical associations. 

— Adopted a substitute resolution calling upon 
the AMA to recognize “brain death” as one of 
the various criteria by which death may be med- 
ically diagnosed. 


(I.A.M.) IMMUNIZATION MONTH 
(OCTOBER) PLANNING BEGINS 

An alarming decline in the number of children 
receiving immunizations against contagious dis- 
ease has led to planning for a second annual 
Immunization Action Month ( I.A.M. ), now 
scheduled for October. 

Eighteen health care organizations and private 
drug firms, under the coordination of the U. S. 
Public Health Service’s Center for Disease Con- 
trol, are cooperating to publicize the need for 
immunization of preschool children. 

This program was approved by the House of 
Delegates of the American Medical Association 
at the recent Annual Meeting in Chicago. 

The goal of the program is to establish and 
maintain awareness among public and private 
health care providers of the need for continuing 
immunization among one to four year old chil- 
dren, to prevent recurrence of contagious dis- 
ease. 

In 1973, I.A.M. officials note some 5.8 million 
one to four year old children were unprotected 


against polio, measles, rubella, diphtheria, per- 
tussis or tetanus. 

They point out that the problem is not limited 
to the ghetto. Only 68.3 percent of one to four 
year olds in suburban areas were adequately pro- 
tected against polio. In 1973 only 34.7 percent 
of preschoolers had been immunized against 
mumps. In 1973, despite the development of an 
effective measles vaccine, 61.2 percent of pre- 
schoolers were immunized against measles. 

I.A.M. intends to reach physicians, public 
health officials, and the public with information 
about the need for immunization. 

Physicians are urged to flag their one to four 
year old patients’ records in order to alert the 
parents referable to immunization needs. 

A southern Illinois dairy firm is printing the 
Illinois State Department of Health’s recommend- 
ed schedule for immunizations on the sides of its 
milk cartons. The message is being printed as a 
public service to make parents and others re- 
sponsible for children’s health care aware of the 
importance of complete protection against child- 
hood diseases. 


POSITION OPEN FOR DIRECTOR 
OF THE NATIONAL CANCER INSTITUTE, 
DIVISION OF CANCER TREATMENT 

The National Cancer Institute is seeking nomi- 
nees to succeed C. Gordon Zubrod, MD, the re- 
tiring director of the National Cancer Institute, 
Division of Cancer Treatment. The salary for 
this position is subject to the $36,000 limit estab- 
lished by the Federal Executive Salary Ceiling. 

Any member of the Louisiana State Medical 
Society may submit the name of a physician or 
physicians having appropriate qualifications to 
Dr. Guy R. Newell, Deputy Director, National 
Cancer Institute, Building 31, Room 11A52, 
Bethesda, Maryland 20014, who is chairman of 
the Search Committee. 


306 


J. Louisiana State M. Soc. 


nUicJfu 



CALENDAR 

PARISH AND DISTRICT MEDICAL SOCIETY MEETINGS 


Society 

Date 

Place 

Ascension 

Third Tuesday of every month 


Calcasieu 

Fourth Tuesday of every month 

Lake Charles 

East Baton Rouqe 

Second Tuesday ot every month 

Baton Rouge 

Jackson- Lincoln- Union 

Third Tuesday of every month 
except summer months 

Jefferson 

Third Thursday of every month 


Lafayette 

Second Tuesday of every month 

Lafayette 

Lafourche 

Last Tuesday of every other month 


Morehouse 

Third Tuesday of every month 

Bastrop 

Natchitoches 

Seoond Tuesday of every month 


Orleans 

Second Tuesday of every month 

New Orleans 

Ouachita 

First Thursday of every month 

Monroe 

Rapides 

First Monday of every month 

Alexandria 

Sabine 

First Wednesday of every month 


Tangipahoa 

Second and fourth Thursdays of 



every month 

1 ndependence 

Terrebonne 

Third Monday of every month 


Second District 

Third Thursday of every month 


Shreveport 

Quarterly — First Tuesday Feb., April, Sept., Nov. 

Shreveport 

Vernon 

First Thursday ot every month 



SEPTEMBER AND OCTOBER 1973 LSMS 
JOURNALS NEEDED 

The LSMS has exhausted its supply of the Sep- 
tember and October 1973 issues of The Journal 
of the Louisiana State Medical Society. Members 
who have copies of these issues, and no longer 
have need for them, are urged to return them to 
the Journal office. 


DEERFLIES CAN TRANSMIT 
RABBIT FEVER, SAYS REPORT IN 
JOURNAL OF AMA 

You can get rabbit fever from a deerfly bite. 
Only then you call it deerfly fever. 

First the deerfly bites a sick rabbit. Then the 
fly bites a man. And the man gets a serious ill- 
ness known to doctors as tularemia — rabbit 
fever. Other insects — mosquitos and gnats — 
also probably are transmitters of tularemia from 
rabbit to man. 

An outbreak of tularemia in Utah in which 
almost three-fourths of the cases stemmed from 
deerfly bites was reported in the October 8, 1973, 
issue of the Journal of the American Medical As- 
sociation. 

Thirty-nine residents contracted tularemia dur- 
ing a three-month period in 1971. Twenty-eight 
of the cases were caused by deerfly bites, and it 
is likely seven more came from mosquito and 
gnat bites, says the report by Lawrence E. Klock, 
MD, Peter F. Olsen, PhD, and Taira Fukushima, 
MD. 

There was an epidemic of tularemia in rabbits 


in Utah in the spring of 1971, and more humans 
were infected than in any of the preceding 20 
years. Infection from sick rabbits has been well 
known and avoided for years. Few of the Utah 
cases stemmed from direct contact with rabbits. 
The insects were the germ carriers. 

Although tularemia has been found in more 
than 60 animals and birds, the jackrabbit is the 
main source of infection in man. Transmission 
from rabbit to rabbit is accomplished primarily 
by a variety of ticks that seldom bite man. 

Tularemia is an uncommon disease. There were 
180 cases reported nationally in 1971. Fifty-five 
percent of these were from insect bites, while in 
the 1940s more than 90 percent of the cases 
came from direct rabbit contact. 

Tularemia brings fever, headache, muscle pains, 
nausea, weakness, lung congestion that may lead 
to pneumonia, and sometimes lymph glands in- 
fection. In earher years it was fatal in from 5 
to 30 percent of the cases, depending on the type 
of the disease contracted. Fortunately, tularemia 
responds readily to antibiotics, with streptomycin 
often being used. Deaths from the disease have 
been virtually eliminated by drug therapy. 


COMMON LANGUAGE URGED FOR 
MEDICAL PROCEDURES 

Almost no one who goes to the doctor or the 
hospital to be treated for illness will ever hear 
about CPT-3. But CPT-3 is an important factor 
in the treatment he or she will receive and how 
much will be charged for it. 


August, 1974 — Vol. 126, No. 8 


307 


MEDICAL NEWS 


CPT-3 means Current Procedural Terminology- 
3rd Edition. 

It is described as “a common language that 
accurately describes the kinds and levels of ser- 
vices provided and that can serve as a basis for 
coverage and fee determination.” 

CPT-3 was developed in book form by the 
American Medical Association as a coded report- 
ing system suitable for computer handling. It 
has been widely adopted across the nation. 

The AMA system assigns a code number to 
each of the thousands of different medical pro- 
cedures that may be performed in treating ill- 
ness. Each number signifies a specific aspect of 
treatment. These numbers can be easily fed into 
computers for purposes of record keeping and 
compilation of bills. 

This system is most successful if it is univer- 
sally used - — • if all doctors and hospitals agree 
on the same code. 

What does CPT-3 mean to the individual pa- 
tient? 

It means better medical care. It’s a check list 
for doctors tO' insure that they have done every- 
thing needed to insure rapid recovery. It makes 
it much easier to monitor costs of health care. 
It speeds and simplifies review procedures, where- 
by a medical committee can check up on the han- 
dling of a case. 

CPT-3 made the news again this spring when 
the AMA dispatched a communication to the So- 
cial Security Administration urging that its ter- 
minology system be adopted for Medicare. Com- 
menting on proposed regulations to revise termi- 
nology and coding under the Social Security Act, 
AMA pointed out that CPT-3 offers what the 
proposed rule requires, a common language. 

CPT-3, the AMA said, has the advantages of 
being developed by the medical profession, with 
cooperation from the various medical specialty 
groups, of having the support of these groups, 
and of being a system which is flexible and allows 
for substantial addition of new procedures. 

Ernest B. Howard, MD, the AMA’s executive 
vice president, told the Social Security Adminis^ 
tration that “It is our belief that CPT-3 will ef- 
fectively meet the present coding needs of Medi- 
care. It is already being required for all insur- 
ance claims statewide in Oregon; a number of 
Medicaid programs are using it. We strongly 
urge that the proposed rules be modified to indi- 
cate that Medicare carriers be authorized to 
adopt the CPT-3 coding system without the neces- 
sity for the detailed approval process currently 
called for in the proposed rules.” 


TODAY’S MEDICINE COSTS CONSUMER 
LESS THAN BEFORE INFLATION 

An individual tablet or capsule of prescription 
medicine cost the consumer, on average, 2.3 per- 


cent less in 1973 than in 1971 and 6 percent less 
than in 1960, encompassing a period of acute in- 
flation in the general economy, according to a 
report of the Pharmaceutical Manufacturers 
Association. 

The decrease in unit price is recorded in data 
prepared by Professor John Firestone of the City 
University of New York. Dr. Firestone’s figures 
indicate a 3 percent rise in the retail price of 
an average prescription during 1973, but the 
average prescription size rose 4.2 percent, hence 
the actual decline in cost when measured in sin- 
gle tablet or capsule units. 

In addition to measuring changes in average 
prescription size, and in the average price of a 
size-adjusted prescription. Professor Firestone 
has also prepared conventional retail and whole- 
sale price indices for prescription pharmaceu- 
ticals. His retail index indicates a rise of 0.3 per- 
cent since 1972 and of 3.2 percent since the base 
year 1967. When 1960 is used as a base year a 
decline of 7.7 percent is found. 


SAFER NEW RABIES TREATMENT 
REPORTED IN AMA JOURNAL 

A new rabies serum without side effects has 
been developed by researchers at the Center for 
Disease Control, the federal government research 
unit at Atlanta, Ga. 

The new serum is extracted from human blood, 
from individuals who have previously been im- 
munized against rabies. Until now, rabies serum 
has been extracted from the blood of horses. The 
horse blood serum is effective, but it produces 
unpleasant and potentially dangerous side effects 
in at least half of those receiving the injections. 

In a report in the January 28 issue of the 
Journal of the American Medical Association, 
the research team recommends that, on the basis 
of their findings. Human Rabies Immune Globu- 
lin (HRIG) be given to those individuals bitten 
by rabid dogs and other animals. 

The serum is given in conjunction with the 
standard rabies vaccine, to speed the body’s im- 
mune defenses against the disease. 

“HRIG appears to be both safer and at least 
as potent as equine antirabies serum, and it 
should be substituted for the equine product,” 
the report says. 

The report is by Michael A. W. Hattwick, MD, 
Robert H. Rubin, MD, Stanley Music, MD, R. 
Keith Sikes, DVM, Jean S. Smith and Michael 
B. Gregg, MD. 


LEUKEMIA SOCIETY OF AMERICA 
FUNDING 43 NEW RESEARCHERS 

Increased contributions reflecting growing 
public interest in efforts to find a leukemia cure 
have made it possible for the Leukemia Society 


308 


J. Louisiana State M. Soc. 


MEDICAL NEWS 


of America, Inc., to fund 43 new investigators 
this year. Their grants became effective July 1, 
1974 according to Dr. Monroe S. Samuels, Presi- 
dent of Louisiana Chapter, 302 Masonic Temple 
Building, New Orleans. 

According to Dr. Joseph H. Burchenal, Vice 
President for Medical and Scientific Affairs for 
the national voluntary health agency, the addi- 
tions bring the Society’s roster to 107 profession- 
al researchers. They will be supported by grant 
payments of $1,580,000 compared to a similar 
expenditure of $1,300,816 last year. The sup- 
plementary income is the result of accelerated 
year-round fund-raising efforts and a 24-hour 
radio/thon held in February to boost the amount 
of monies earmarked for research purposes, he 
said. 

Among the new Leukemia Society of America 
researchers are 9 Scholars, 15 Special Fellows 
and 19 Fellows. Scholars will receive $100,000 
for their five year programs while the others will 
be given awards of $31,000 and $19,000 in the 
respective categories for two year periods. 


STUDENT TREND TO FAMILY PHYSICIANS 
CONFIRMED BY SURVEY 

A survey of 1974 graduating medical students 
by the American Academy of Family Physicians 
shows that (1) more medical students than ever 
before are choosing family practice as their spe- 
cialty, and (2) that the demand for first-year 
spaces in family practice residencies exceeds the 
number of spaces available by almost two to one. 

The purpose of the study, conducted by the 
Academy’s Education Division, was to determine 
what deficit, if any, existed in first-year spaces 
before the National Intern and Resident Match- 
ing Program (NIRMP) results are released. 

One hundred and sixty of the 191 approved 
residencies have responded so far. As of Febru- 
ary 4, these training units reported 2,014 grad- 
uates seeking first-year spaces. Estimated spaces 
available stand at about 1,170, leaving a deficit 
of 844 graduates desiring first-year spaces. 

Dr. Robert Graham, assistant director of the 
AAFP Education Division, said residency direc- 
tors have indicated to him that if enough finan- 
cial and faculty support could be obtained, extra 
spaces might be created to absorb at least some 
of this deficit. 

Dr. Graham also estimated that approved fam- 
ily practice residency training programs will 
probably reach the 230 mark by January 1, 1975. 
This, he says, coupled with program expansion, 
hopefully will create enough second-year spaces 
to allow some of the unsuccessful 1974 appli- 
cants to transfer from interim training of another 
type to family practice residency training in 
1975. 


Dr. Graham anticipated that family practice 
programs will graduate more than 350 family 
physicians this year. This increase, and future 
estimates, indicate healthy progress toward the 
Academy’s announced goal of having at least 25 
percent of the nation’s medical school graduates 
enter family practice. 


ACUPUNCTURE FAILS TO CURE 
DEAFNESS IN RESEARCH STUDY 

Acupuncture failed to cure nerve deafness in 
a carefully controlled scientific study at Michi- 
gan State University, says a report in the April 
issue of Archives of Otolaryngology , a publica- 
tion of the American Medical Association. 

The use of acupuncture for anesthesia and as 
treatment of a number of ailments has attracted 
the attention of both the public and the medical 
community in recent years. Within the past two 
years an increasing number of hearing-impaired 
patients have been undergoing acupuncture treat- 
ments. Several earlier studied had reported tenta- 
tively some success. 

The research group at Michigan State brought 
in a trained acupuncturist with 15 years experi- 
ence to treat an ex-serviceman deafened by firing 
weapons in combat in World War II. He was 
given eight treatments at one-week intervals. His 
hearing was measured scientifically with a bat- 
tery of audiological tests before, during and after 
the treatments. 

There was no evidence that the acupuncture 
treatments resulted in any measurable change in 
the patient’s sensorineural hearing loss, the re- 
searchers report. 

The study was by William F. Rintelmann, PhD, 
Herbert J. Oyer, PhD, Janis L. Forbord, and 
Phyllis L. Flowers, of the Department of Audi- 
ology and Speech Sciences at Michigan State, 
East Lansing, Mich. 


NHC SELECTS THREE DEMONSTRATION 
PROJECTS IN SHORTAGE AREAS 

Appalachian Kentucky, rural Maine and New 
Orleans, La., have been selected by the National 
Health Council (NHC) as sites for three demon- 
stration projects aimed at encouraging health stu- 
dents to practice in shortage areas following 
graduation. 

In making the announcement concerning the 
demonstration projects, Edward H. Van Ness, 
NHC executive director, explained that the proj- 
ects are part of NHC’s Manpower Distribution 
Project, undertaken to explore ways to improve 
one of the major health care problems in the 
U.S. today — the maldistribution of health man- 
power. The NHC believes that if health person- 
nel are to be attracted to rural and inner city 


August, 1974 — Vol. 126, No. 8 


309 


MEDICAL NEWS 


areas where they are needed most, more atten- 
tion must be given to encouraging them to do so 
during their professional education. 

Funded through a grant of $125,000 to the 
NHC from Manpower Development and Training, 
Office of Education, Department of Health, Edu- 
cation and Welfare, the demonstration projects 
will test different methods of influencing stu- 
dents in the health professions to practice in 
areas of greatest need upon completion of train- 
ing. 

Successful methods used in these demonstra- 
tion projects will be publicized and, it is hoped, 
replicated in other regions of the United States. 


THE NEED FOR CONFIDENTIALITY 

The Council on Medical Services of the A.M.A. 
has proposed a set of guidelines on confidential- 


ity, and they include the following which are of 
relevance to Blue Shield : 

• Emphasize to claims personnel the necessity 
for preserving the confidentiality of medical in- 
formation. 

• Instruct all personnel having access to pa- 
tient medical information not to divulge that in- 
formation to the patient or his employer under 
any circumstance. 

• Discourage the practice of indiscriminate 
photocopying of physician’s records. 

• Encourage claims examiners, when request- 
ing additional information from physicians for 
purposes of claims processing, to be specific as 
to their needs. 

By reminding Plan employees again of the 
need to follow these rules closely. Blue Shield 
can best serv^e subscribers and the medical pro- 
fession. 


310 


J. Louisiana State M. Soc. 





euieu/6 


Thyroid Tumors. Lymphomas. Granulocytic Leu- 
kemia', by M. Fiorentino, R. Vangelista, and 
E. Grigoletto, eds. Piccin Medical Books, Pa- 
dova, 1972, 210 p. 

This book is a compilation of papers presented 
at the second Padua Seminar on Clinical Oncol- 
ogy. As is often the case with books of this kind, 
certain problems are apparent such as, a) con- 
siderable time lag between the conference and 
the publication; b) the fact that many manu- 
scripts do not present any new data; c) marked 
unevenness of the published material with some 
of the papers being of interest while others are 
almost worthless. 

It consists of 19 papers organized into 3 sec- 
tions. Nine papers deal with thyroid tumors, five 
with chronic granulocytic leukemia and seven 
with malignant lymphomas. The report by P. 
Stryckmans, et al, contains material from an ex- 
cellent study and should be of interest to anyone 
concerned with the kinetics of leukocytes in leu- 
kemia and with the pathogenesis of chronic gran- 
ulocytic leukemia and its acute transformation. 
The paper by I. H. Krakoff, et al, entitled “A 
Perspective of Intensive Treatment Aiming at 
Prolonged Control and/or Eradication of Chronic 
Granulocytic Leukemia” is nothing else than a 
brief abstract with very limited information and 
is neither very informative nor very useful. The 
paper by S. A. Rosenberg entitled “The Results 
of Radical Radiotherapy with or Without Com- 
bination Chemotherapy (MOPP) in Hodgkin’s 
Disease” presents a concise view of present day 
concepts on therapy of this disease, but contains 
no new information. The paper by U. Veronesi 
entitled “Diagnostic Laparotomy with Splenec- 
tomy in Hodgkin’s Disease and in the Malignant 
Lymphomas” contains a description of the sur- 
gical technique for staging laparotomies which 
could be profitably consulted by surgeons not 
familiar with the purpose of this operation. 

This book should be of limited interest to hema- 
tologists, endocrinologists, radiotherapists and 
medical oncologists interested in, or conducting 
clinical research on the treatment of neoplasia. 
However, it is unlikely that they will find much 
new, original, or highly provocative information. 

German Beltran, MD 


Human Sexuality, published by the AMA, 1972, 
299 p, $5.95. 

This book on human sexuality, prepared and 
published by the American Medical Association, 
is long overdue. It contains contributions from 
the foremost experts in the field of human sex- 
uality in the United States and includes contribu- 


tions from physicians of various backgrounds and 
specialties, clergymen, medical students and law- 
yers who are well versed in this field. 

It is divided into four parts. The first part is 
entitled, “The Physician and Human Sexuality,” 
and in this section the role of the physician, the 
doctor-patient relationship, and the meanings of 
human sexuality are discussed. In Part II, “The 
Physician and Human Sexual Development” 
stresses the development of human sexuality from 
childhood, pubescence and adolescence to early 
and late adulthood. “The Physician and Human 
Sexual Response” comprises Part III. The sexual 
relationship, the sexual response system, relating 
to the physiology of sex, the methods of coitus, 
evaluating sexual complaints, and the problems 
of male and female responses are all discussed 
at length. This section concludes with a chapter 
on disease and surgery and one on variations of 
sexual responses. Part IV is entitled, “The Phy- 
sician, Sex and Society”. The sociological and 
legal aspects of human sexuality are discussed in 
detail. Sexual education and the role of the phy- 
sician are highlighted. 

It contains numerous references and appen- 
dices relating to evaluation, history and attitudes, 
and a sexual education reading list. An extensive 
biblography and index are also included. 

This volume is especially well written and ful- 
fills a void in the education of a physician. As 
pointed out in the text, until recently sex educa- 
tion and methods of treating sexual dysfunctions 
have been sorely omitted from the medical cur- 
riculum. Mature physicians who have not had 
the opportunity to participate in courses on sex- 
ual education and treatment of sexual dysfunc- 
tions will find this book a must for their li- 
braries. It is stated that in 1961 there were only 
three medical schools offering a sexual education 
course; and although this number is increasing, 
there are still very definite inadequacies in the 
training of physicians in the problems of manag- 
ing human sexuality. 

The publication of Human Sexuality should do 
much to stimulate the inclusion of more courses 
in human sexuality in the curriculum of medical 
students. 

There is a deficiency in the book of more com- 
plete coverage of the newer techniques in treat- 
ing sexual dysfunctions based on learning theory 
and behavior therapy. This observation may be 
this reviewer’s bias. 

This book on human sexuality is done in good 
taste, is thoroughly readable, and should be ex- 
tremely useful to all practicing clinicians. 

C. B. SCRIGNAR, MD 


August, 1974 — Vol. 126, No. 8 


311 


INFORMATION FOR AUTHORS 

Manuscripts should be typewritten, double- 
spaced on firm white paper 8'/2 x I I inches with 
adequate margins. This applies to all text elements: 
references, legends, footnotes, etc. Single spaced 
manuscripts and photo copies will not be consid- 
ered. The original and one duplicate copy should 
be submitted. Manuscripts are received with the 
explicit understanding that they are not simulta- 
neously being considered by any other publication. 
Accepted manuscripts become the property of 
THE JOURNAL and may not be published else- 
where without permission from the author and 
THE JOURNAL. Manuscripts are subject to copy 
editing. 

References must be limited to a reasonable num- 
ber. They will be critically examined at the time 
of review and must be kept to a minimum. Personal 
communications and unpublished data should not 
be included. The following minimum data should 
be typed double spaced: names of all authors, 
complete title of article cited (lower case), name 
of journal abbreviated according to Index Medicus, 
volume number, first and last page numbers, and 
year of publication. All references must be cited 
in the text and the list should be arranged in 
order of citation, and not alphabetically. 

Illustrations consist of material which cannot be 
set in type. Photographic material should be sub- 
mitted as high contrast, glossy prints. Drawings 
and graphs must be done professionally in india 
ink on high grade white drawing paper. Omit 
illustrations which do not increase understanding 
of text. Composite figures and figures labeled A, 
B, C, etc., cannot be reproduced adequately in 
column width without loss of detail; therefore, each 
segment must be considered a separate illustration. 
Illustrations must be limited to a reasonable num- 
ber. Four illustrations should be adequate for a 
manuscript of 1 6 to 18 typed pages. Legends 
should be typed on a separate sheet of paper. 
The following information should be typed on a 
gummed label and affixed to the back of each 
illustration: figure number, title of manuscript, 

name of senior author, and arrow indicating top. 

Tables should be self-explanatory and should 
supplement, not duplicate, the text. Tables must 
be numbered consecutively, each must have a 
title, and each should be typed on a separate 
sheet of paper. 

Subheads should be used to provide guidance 
for the reader. This format is flexible but the 
subheads would ordinarily include: Methods and 

Materials, Case Reports, and Discussion. 

Reprint orders will accompany galley proofs 
which are sent tor author's corrections. 


Rondomycin 

(methacycline HCI) 


CONTRAINDICATIONS: Hypersensitivity to any of the tetracyclines. 

WARNINGS: Tetracycline usage during tooth development (last half of pregnancy to eight 
years) may cause permanent tooth discoloration (yellow-gray-brown), which is more 
common during long-term use but has occurred after repeated short-term courses. 
Enamel hypoplasia has also been reported. Tetracyclines should not be used in this age 
group unless other drugs are not likely to be effective or are contraindicated. 
Usage in pregnancy. (See above WARNINGS about use during tooth development.) 

Animal studies indicate that tetracyclines cross the placenta and can be toxic to the de- 
veloping fetus (often related to retardation of skeletal development). Embryotoxicity has 
also been noted in animals treated early in pregnancy. 

Usage in newborns, infants, and children. (See above WARNINGS about use during 
tooth development.) 

All tetracyclines form a stable calcium complex in any bone-forming tissue. A decrease 
in fibula growth rate observed in prematures given oral tetracycline 25 mg/kg every 6 
hours was reversible when drug was discontinued. 

Tetracyclines are present in milk of lactating women taking tetracyclines. 

To avoid excess systemic accumulation and liver toxicity in patients with impaired renal 
function, reduce usual total dosage and, if therapy is prolon